# EndoProMag.com

> The advocate for today's endoscopy professional.

> Admin Email: vikas@insightfultechno.com


## Posts
### Crohn’s Disease: Can AI Help With Endoscopic Scoring?
The journal Clinical Gastroenterology and Hepatology has shared a new study that explores whether artificial intelligence may help with endoscopic scoring of Crohn’s disease (CD).
Endoscopic scoring of CD is challenging because mucosal disease is patchy with highly variable morphology, size, and severity. Computer vision may help quantify disease activity with similar performance as standard instruments like the Simple Endoscopic Score for Crohn's Disease (SES-CD), according to the study abstract.
Colonoscopy videos from the STARDUST and SEAVUE phase 3 clinical trials underwent post-hoc computer vision endoscopic (CVE) assessment to quantify CD mucosal ulceration and injury. A segmentation model was trained on hand annotations of images performed by two gastroenterologists, predicting ulcer area, severity, and relative size.
Predicted ulceration and general mucosal injury were then spatially mapped to the ileum and colon to quantify CD burden. CVE ulceration and general injury values were compared to the SES-CD in terms of disease quantification, localization, and agreement with end-of-study clinical remission.
Ulcer semantic segmentation models matched the performance of gastroenterologist annotators, with neither performing better on qualitative review of disagreements. CVE measures were highly correlated with SES-CD scores, though there was expected poor correlation with the degree of stenosis.
The conclusion was that CVE “provides a means for automated ulceration and mucosal injury quantitation that shows conceptual agreement with SES-CD and offers new capabilities to improve the granularity and personalization of endoscopic disease assessment in CD.”
To read more of the study, click here.

### Health Tech Academy Launches Endo Certification Program
AUSTIN, Texas—Health Tech Academy recently introduced a fully online endoscopy technician program designed to launch students into the growing field of GI healthcare. Created in partnership with clinical experts, this program focuses on real-world skills such as patient prep, scope care, sterilization practices, and procedure room support.
The six-week curriculum blends on-demand learning with live coaching sessions, allowing students to train on a flexible schedule while receiving professional guidance. Open to anyone with a high school diploma or GED, the program helps learners build confidence and competence for support roles in hospitals, outpatient clinics, and endoscopy centers.
The structured weekly curriculum covers key topics such as endoscope processing, patient safety, anatomy of the digestive system, infection prevention, and procedural assistance—taught by experienced industry professionals. Health Tech Academy (HTA) created its endoscopy technician certification program to prepare future healthcare workers with the technical skills, clinical knowledge, and patient-focused mindset needed to support today’s GI care teams.
“We’re excited to introduce a program that opens doors for students to enter the field of endoscopy with confidence,” said Shamsah Noorani, CEO of Health Tech Academy. “In just six weeks, learners can gain the hands-on knowledge and technical foundation needed to pursue certification and step into essential roles on GI care teams. Our goal is to make healthcare training more accessible—while preparing students to have an immediate, positive impact in clinical environments.”
Health Tech Academy’s program connects students with seasoned healthcare professionals who bring real-world experience from GI clinics and hospital settings. Through one-on-one mentorship and expert-led support, learners receive the kind of personalized guidance rarely found in traditional education models. The program emphasizes skill-building in a low-pressure, flexible environment that adapts to each student’s pace and needs. With streamlined coursework, prompt feedback, and an all-inclusive tuition that covers learning materials and certification prep, this online pathway offers an accessible, career-focused alternative to conventional training programs.
“Our new Endoscopy Technician program equips students with the technical training, guided mentorship, and job-ready skills needed to thrive in GI healthcare settings,” said Danish Khan, Product Manager at Health Tech Academy. “From the engaging online modules to personalized career planning tools and our career evaluation assessment, every part of the program was built to address workforce needs and prepare learners for in-demand roles in endoscopic care.”
This new Endoscopy Technician program joins Health Tech Academy’s growing lineup of career-focused healthcare certifications, which includes training for medical assistants, sterile processing technicians, and more. Each program is built for flexibility, speed, and accessibility—offering a streamlined path into healthcare without the expense or timeline of a traditional degree.
 

### Free Webinar Exploring IBD’s Impact on Women’s Health
Cedars-Sinai’s upcoming Sept. 13 conference on Women and Inflammatory Bowel Disease (IBD) will highlight women’s unique experiences with the disorder and provide relevant information and guidance for both patients and providers, says gastroenterologist Puja V. Khanna, MD, the clinical director of the Cedars-Sinai Inflammatory Bowel Disease Women’s Health Program.
“In the morning, we will host a clinician track on best practices for treating women with IBD,” Khanna said. “In the afternoon, patients and families are invited to a dedicated session covering pregnancy, fertility, nutrition, mental health and more. There is also time for patients and providers to connect.”
An estimated 3 million people in the U.S. have inflammatory bowel disease, according to the Centers for Disease Control and Prevention. The disorder produces chronic and often destructive inflammation in the digestive tract. The two most common forms of IBD are Crohn’s disease and ulcerative colitis. While some cases can be mild and manageable, many IBD patients are faced with a constellation of health problems including severe diarrhea, malnutrition, dangerous blood clots, and extensive and painful scarring.
IBD occurs in men and women at about the same rate, but the disease can leave women facing unique health challenges. There can be difficult decisions about proceeding with certain drug therapies while trying to conceive or during pregnancy and menopause.
“For women living with IBD, simply knowing that their needs are recognized and that there is a community and program designed for them can be incredibly empowering,” Khanna said
The Cedars-Sinai Newsroom interviewed Khanna about how IBD impacts the health and wellbeing of women, including finding a good healthcare provider and effective therapies available to them. 
In what ways can IBD impact women and men differently?
While inflammatory bowel disease occurs at about the same rate in both sexes, women often present differently. After age 30, Crohn’s disease is more common in women than in men. We also see sex-specific patterns: Women are more likely to have Crohn’s limited to the colon, less extensive ulcerative colitis, and more frequent extraintestinal conditions, such as eye inflammation and skin disorders. Recognizing these differences is critical for timely diagnosis and effective management.
Are there differences in diagnosis, disease course or treatment protocols for women?
The diagnostic workup for IBD is the same regardless of sex and typically involves colonoscopy, imaging, lab testing. However, the course of the illness can vary. Women may experience flares around hormonal changes, such as those occurring during menstruation or pregnancy.
Treatment approaches are generally the same for men and women, but side effects can differ. For example, women are more likely to develop drug-induced lupus with certain biologic therapies. Providers must stay alert to sex-based responses to various treatments for IBD. For women of childbearing age, therapy selection must consider whether a medication is safe in pregnancy. Most of them are, but not all.
Does IBD impact a woman’s reproductive life, including menstruation, fertility and pregnancy?
Absolutely. Many women report worsening symptoms during menstruation due to hormone fluctuations. Fertility can be reduced in women with active inflammation or prior pelvic surgery, although more research is needed on that front. Pregnancy outcomes are best when disease is in remission for at least three to six months before conception. Interestingly, we have found that some women with IBD may actually experience improvement in symptoms during pregnancy.
Most IBD medications can be safely continued during pregnancy, particularly when the disease is under control. Methotrexate, an immunosuppressant medication, should be avoided. There are other classes of medications, such as JAK inhibitors, whose safety and use should be discussed with your provider. At Cedars-Sinai, our IBD Pregnancy and Fertility Clinic brings gastroenterology and obstetrics together so women receive coordinated care.
Do women find it challenging to get an accurate IBD diagnosis? What advice would you offer?
Many women do face delays. They may see multiple providers before reaching a gastroenterologist who recognizes their symptoms as inflammatory bowel disease. My advice is to advocate for yourself. If you are not being heard, seek a second opinion, ideally at a dedicated IBD center. A colonoscopy and appropriate testing are essential to confirm the condition.
How do IBD patients benefit from a multidisciplinary approach to care? 
One young woman in her 20s came to me after years of aggressive Crohn’s disease. She had seen specialists across the country, endured multiple treatments, and was facing another surgery. She broke down in tears, telling me she felt abandoned by her doctors. I reassured her and then brought her case to our weekly IBD meeting where top experts could collaborate on her care. That sense of not being given up on, and of building a trusted partnership with a care team, can be life-changing for patients living with a chronic illness.
The Women and IBD conference will take place at Cedars-Sinai on Saturday, Sept. 13. Attendance is free but registration is required.
Those interested in attending can email groupibdwomensprogram@cshs.org to register and receive more information.

### Endoscopy Innovation Improves Early Detection of Esophageal Cancer
A team from Helmholtz Munich, the Technical University of Munich (TUM), and the Medical University of Vienna has introduced a new imaging approach known as oxygen-enhanced endoscopy (O2E), which enables highly precise detection of cancerous lesions in the esophagus. According to research published in Nature Biomedical Engineering, this technique can reveal even subtle pathological alterations in tissue, paving the way for earlier identification and diagnosis.
O2E merges optical coherence tomography—which provides detailed images of tissue architecture—with optoacoustic imaging, a method that employs light pulses and ultrasound to visualize tiny blood vessels in deeper tissue layers. By combining these two technologies within a single capsule that rotates to scan the entire esophagus, O2E delivers high-resolution, three-dimensional images of the esophageal lining.
Researchers tested the O2E system in a pilot study by examining both animal esophageal tissue and human samples from individuals with Barrett’s esophagus, a condition that can precede esophageal cancer. The team successfully distinguished healthy tissue from areas with abnormal cell changes, precancerous developments, and cancerous growths. Additionally, they conducted proof-of-concept tests on the inner lip of a volunteer, taking advantage of its comparable tissue features.

### Workplace Boundaries
You’re having a very busy day with many patients on the schedule. You’re documenting information regarding a patient you just interviewed. During your hectic day, a co-worker approaches you says, “I don’t think I will have time to finish these calls; could you call these patients?” This same co-worker has periodically asked you to complete tasks that they are responsible for in the workplace. Despite having a full plate of tasks, you agree to help your co-worker.
In the above workplace scenario, what just happened? You think you’re helping a co-worker, but this person is repeatedly asking you to do their work. What is happening is a violation of boundaries. Of course, filling in to help a co-worker is fine, but when it becomes habitual, then it’s an issue.
Editor’s Note: The following package deals with setting boundaries in the workplace, such as boundaries with colleagues, bosses and patients, and against noise and distractions. Boundary-setting is more important than ever, because modern medical settings are more stressful than perhaps ever before, with the exceptions of say, COVID, or times of war. We have limited control over the workplace, but the following articles focus on where improvements might be possible.
What is a Boundary?
A boundary is a limit defining you in relationship to someone or to something. Boundaries can be physical and tangible or emotional and intangible. For example, a physical boundary is a fence, which identifies spatial limitations. Physical boundaries are concrete and easily identifiable. However, emotional boundaries are much less clear, which can make them more challenging to establish and enforce.
A line in the sand is a clear physical boundary. When a person steps over that line, they have violated the boundary. This same analogy can be used in emotional boundaries as well. For example, if a co-worker makes an inappropriate comment, they have crossed a line.
Having effective boundaries will not distance you from others. The boundaries prevent conflict and bring people together because, generally speaking, everyone knows what acceptable behavior is. This article will help you establish boundaries while still maintaining excellent relationships with co-workers.
Causes of Boundary Violations
Emotional Baggage
Everyone enters the workplace with some baggage. When people walk into the workplace, they do not leave their baggage by the door. Baggage brought into the workplace can affect interactions with coworkers, potentially leading to significant issues with boundaries. Many factors come into play, including the style of communication each person experienced in their families. Some people come from family situations where nurturing relationships were seen and modeled. Unfortunately, other people come from situations where significant dysfunction was present, and those styles of behavior walk into the workplace. Some people don’t realize they are violating boundaries in their communication style because in their environment, such behavior was acceptable.
Presenteeism
This term means that employees are physically present, but due to physical or emotional issues, are distracted to the point of reduced productivity. While absenteeism means they are physically absent, presenteeism means they are physically present, but due to other issues they are unable to function effectively to complete work-related assignments.
Many of the causes of presenteeism are rooted in psychological issues. For that reason, the workplace needs to have tools to help struggling employees, including stress-management support and, when needed, employee assistance programs. The privacy and confidentiality of such programs must be fiercely guarded—from both other employees and management—or employees will not feel comfortable using them.
Presenteeism leads to weak interpersonal relationships. Combining emotional baggage and presenteeism can lead to workplace toxicity and exacerbate the ensuing boundary violations.
Types of Boundaries
Co-worker Boundaries
Everyone in the workplace has job responsibilities and duties. In the example above, an employee was violating a co-worker’s boundaries by continually asking them to do their work. However, boundaries may not be directly related to job responsibilities. For example, a co-worker who often uses crude language or tells inappropriate jokes is also violating boundaries. This employee is violating the boundaries of people who expect the workplace to be free of bawdy language and tasteless or insulting remarks.
Patient Boundaries
There are appropriate interactions with patients, and then there are behaviors that cross the line, such as talking to patients about personal issues. Of course, chatting with patients about pets or a new restaurant in town is acceptable, but talking to patients about an abusive boyfriend is not appropriate.
Setting Boundaries
The following will help with the mechanics of boundary setting.
Follow the ABC Rule
ABC = Always Be Courteous. A person can still be friendly while setting boundaries. For example, in my work as a keynote speaker and workshop leader, the person who introduces me sets boundaries regarding mobile phones, and they’re always pleasant about it.
They kindly advise the audiences to please put their phones on vibrate. There’s no need to yell at people about the volume of their phones.
Identify Your Limits
The first step in setting boundaries is determining your limits, which can be emotional, mental, physical or spiritual. You set limits by noticing what you can tolerate and accept, as well as what makes you feel uncomfortable and stressed. These feelings will help you clarify your limits. Your limits are personal and are likely to be different than the limits of other people.
In one of my many boundary-setting workshops, an attendee mentioned a co-worker who had a habit of eating her lunch in front of her computer. The problem is that she liked eating fish and some co-workers thought the smell of the food was bothersome. A co-worker politely mentioned to this person the fish issue. The fish-eating co-worker immediately apologized and mentioned having no idea of the food having a strong odor.
Overall, listen to your feelings; they will tell you if boundaries have been violated. There are certain feelings that often signal boundary violations, including feelings of discomfort, resentment or guilt. These feelings are symptoms of boundary violations.
Clarity
Workplace boundaries must be clearly outlined so people in the workplace know what behaviors are acceptable. Each team member understands what to do, how to do it, and when to do it. This creates an efficient workplace environment. Managers must define and enforce the boundaries.
Passive-Assertive-Aggressive Behavior
Passive Behavior
Passive people are submissive and sometimes have feelings of low self-esteem. They do not stand up for themselves and are often sometimes referred to as doormats, in that other people can step all over them. Since some passive people feel powerless, they may have weak or nonexistent boundaries. They focus on the needs of other people. Even if they’re really busy, if a co-worker asks them for help, they will relinquish their own responsibilities to do someone else’s work.
Aggressive Behavior
Aggressive people are sometimes arrogant and may have unrealistic feelings of self-importance. Some belittle others and attack those who don’t share their views. Some aggressive people are tyrannical and have poor boundaries, since all their attention is on themselves. They focus only on their needs. If a co-worker asks them for help, they may refuse and be unpleasant.
Assertive Behavior
Assertive people are confident and self-accepting. These people have clearly defined boundaries. They focus on meeting their needs and the needs of others in a harmonious fashion. If they’re very busy and a co-worker asks them for help, they will politely explain that they can’t help now but will give them options to help meet their needs, such as checking back later or suggesting another person who might be able to assist.
Assertive people are comfortable and confident with themselves and have well-defined boundaries. The ideal workplace scenario is to have as many assertive people as possible since these types of individuals create a friendly and productive workplace. See Table 1 for a summary of passive, assertive and aggressive behaviors.
Handling Boundary Violations
Language
I suggest using “I” language and avoiding “you” language. “You” language can sound threatening, while “I” language comes across as pleasant, yet firm. For example, let’s say you have been asked to do excessive work and you’re feeling overwhelmed. These are two possible responses:
 	“You” version: “You’re giving me too much work. You have to stop this!”
 	“I” version: “I’m feeling overwhelmed. Let’s talk about solutions to manage the workflow.”
The “I” language version focuses on the sender’s feelings and is not accusatory. The response also blends in a solution-oriented perspective.
I also suggest avoiding “why” language. For example, a co-worker has not been completing assigned tasks. You have been forced to cover for this person and you’re feeling frustrated. You have reached a point where you have to say something. These are two possible responses:
 	“Why” version: “Why aren’t you getting your work done?”
 	“What” version: “What’s going on that’s leading to your assignments not being done? I notice this has been happening more often. Let’s talk about the situation.”
The “what” version is more friendly. The response also blends in a solution-oriented perspective.
Get It in Writing
There should be clearly written guidelines for employee job-related tasks and guidelines for interpersonal behavior to avoid boundary violations. Having clearly written guidelines moves the conversation from subjective to objective.
Two-Way Street
If you want people to respect your boundaries, then you must respect their boundaries. Be conscious of what you are asking of others. Is it reasonable?
Balance
We want clearly defined boundaries, but we must also allow for some flexibility. Our boundaries may need to vary based on the situation.
Get People Back on Track
People sometimes get distracted and go on tangents and need help getting back to the task at hand. The details of your co-worker’s vacation may be fun, but excessive discussions can take away from job responsibilities, hence violating your boundaries of completing assignments. In this situation, it’s important to respond gracefully, such as by saying, “Your vacation sounded wonderful. I need to complete this documentation, but let’s chat at lunch and you could fill me in more.”
Boundaries with Patients
Healthcare professionals must use caution when talking to a patient about their personal lives. The patient’s role is not to be that of a counselor. Only share limited and general information about life outside the workplace. However, some information can be shared if there is a benefit to the patient, such as an encouraging statement. If you had the same medical issue and are doing well, that type of discussion is certainly acceptable.
The actions of patients trigger emotional reactions among professionals. These feelings include sadness, anger and protectiveness, among many other feelings. It is normal to feel such emotions, but caution must be used in how these feelings are expressed. Emotional reactions can interfere with boundaries, including becoming too attached to certain patients while ignoring others. Becoming aware of these emotional reactions is the first step to looking at how they affect working with patients.
Terms of Endearment. Using terms of endearment can initially appear to be a gentle and kind gesture but can create issues. Calling a patient “sweetie” or “honey” may appear to be comforting to that patient, but it may also suggest a more personal interest than intended. It might also suggest favoritism to other patients who are not called by those nicknames. Some patients may find such endearments offensive or patronizing.
It is a good practice to avoid using these terms, as doing so could blur the clarity of a professional’s role in the life of the patient.
Burnout. Caregivers must learn to care for themselves. Providing care to frail and vulnerable patients is deeply rewarding, and sometimes deeply draining. The kind of giving that leads to burnout tends to involve behaviors done outside of the boundaries of one’s job. Being aware of the boundaries of one’s role and striving to adhere to those boundaries helps protect the caregiver from the destructive impact of burnout.
Gifts and Favors. Giving gifts to a patient or receiving gifts from a patient can blur the line between a personal relationship and a professional one. Have written guidelines for employees to determine what is acceptable as a gift. The same rules apply to favors, such as staying after work hours to “do a favor” for a patient.
Secrets. Do not keep secrets with patients. Do not share personal secrets with a patient and ask them to keep it a secret. Do not agree to keep secrets patients tell you. Secrets are different from confidentiality. Confidential information is shared with a few other members of a team providing care to a patient. Personal secrets compromise role boundaries.
Putting It All Together
Boundary issues will always be a part of the workplace due to a variety of factors, such as the communication skills and personal histories people bring into the workplace. A healthcare environment is a therapeutic milieu. To keep the environment therapeutic, boundaries must be established and implemented.
Through the strategies discussed in this article, you can minimize boundary issues. When equipped with the right set of skills, you can set boundaries while simultaneously creating positive workplace relationships that will benefit both your co-workers and your patients.

### Overstimulated at Work?
More and more people in today’s fast-paced working environment feel perpetually on edge: unable to focus, plagued by a nonstop stream of notifications, and exhausted before the day even ends. This is due in part to overstimulation, which, in the healthcare setting, can be worse than almost anywhere else.
Overstimulation is when the brain becomes overwhelmed by too much sensory, cognitive and emotional input—in other words, far more than it can efficiently process. Overstimulation may result in irritability, exhaustion, lowered productivity and, finally, burnout. The modern workplace, with its open-concept offices, constant digital communications, and the demand for employees to be “always on,” has become a prime contributor to this growing problem.
Overstimulation is different from stress. Overstimulation is the state one goes through after being put through excessive use of information or sensory input in a short period of time. This could include noise, bright light, constant meetings, or multitasking in the hyper-connected world. When overstimulated, the brain can’t filter distractions and is unable to focus on the processing of emotions or any meaningful work.
Overstimulation occurs when incoming information, intearctions and sensory experience combined outpaces the brain’s capacity to process. A 2023 study in The Journal of Neuroscience reported that sensory overload complaints had increased 40% from pre-pandemic levels; this may well be a shift exacerbated by a return to office spaces and a surge in digital communication.
The Modern Work Environment
We work a lot differently now than we did just 15 years ago, and many of the innovations in the modern workplace—well-intentioned to help people collaborate and work more efficiently—surely serve to increase overstimulation. Here’s how:
The Open-Office Dilemma
Open-concept offices were once lauded as the future of collaboration. In reality, they’re often a sensory minefield of conversation, ringing phones, clacking keyboards, and impromptu meetings—making it nearly impossible for workers to focus. In that way, they’re not all that different than your typical nurse’s station or surgery center office. Researchers at Harvard Business Review found that, due to noise and distraction, employees in open offices experience a staggering 15% loss in productivity.
The average worker gets 121 emails a day and countless messages, texts and notifications. And with the expectation of immediate response, employees are constantly switching between tasks, leading to cognitive fatigue. According to a study by the University of California at Irvine, it takes an average of 23 minutes to refocus after an interruption, making digital overload one of the biggest contributors to overstimulation in the workplace.
Back-to-Back Meetings and Multitasking
Most employees find themselves caught in a vicious circle of back-to-back meetings, leaving little or no time for deep work. The compulsion to multitask—doing emails while on calls or messaging during meetings—prevents full engagement and increases cognitive strain.
The “Always-On” Culture
With the introduction of remote and hybrid work, the line between personal and professional life has continued to blur; people may feel obligated to check emails after hours or respond to late-night messages, leaving little time for actual mental recovery.
What Employers Can Do to Reduce Overstimulation
Creating a healthier work environment isn’t just about reducing stress; it’s about rethinking how we structure work to minimize cognitive overload. Employers can make a difference by instituting changes that protect mental well-being while sustaining productivity.
1. Normalize Quiet Spaces and Flexible Work Zones
While collaboration is invaluable, employees also need spaces where they can work without interruptions. Quiet rooms, soundproof pods, and “focus hours” can help temper the sensory overload of open offices.
2. Rethink Communication Overload
Organizations should set norms around communication to limit unnecessary digital interruptions. Encouraging scheduled check-ins rather than constant instant messaging, and implementing email-free focus periods, can make a big difference.
3. Prioritize Meaningful Breaks
Brief, intentional breaks throughout the day—say, walking outside, meditating or simply looking away from screens— reset the brain and prevent overstimulation from building up.
4. Create Meeting-Free Time Blocks
Companies like Shopify and Asana have successfully introduced “meeting-free days,” allowing employees uninterrupted time for deep work. Limiting meetings to specific time blocks can give employees more control over their schedules.
5. Encourage Separation of Work and Personal Life
Employers should model healthy boundaries by not intruding on employees’ time outside of work. Simple things, such as discouraging after-hours emails and setting clear expectations around availability, can prevent the always-on mentality that contributes to overstimulation.
What Employees Can Do to Protect Themselves
While organizational change is crucial, employees can also take proactive steps to manage overstimulation in their daily routines. These tips include:
Identify your triggers. Notice where and when overstimulation usually occurs, such as a noisy office, constant email pings, or back-to-back meetings.
Set boundaries with your digital tools. Turn off nonessential notifications, batch and check emails, and set “do not disturb” on during your focus time.
Take a sensory break. This may be breathing exercises, time away from screens, or sometimes just closing one’s eyes for a few moments—anything to help the nervous system reboot.
Express need. People are different. If some of the factors that are overstimulating you can be improved, talk with your manager or anyone else who may be able to help.
The Future of Work Deserves Smarter Spaces
Overstimulation is a challenge that calls for meaningful steps toward healthier, more sustainable work environments. It means rethinking building layouts, digital communication habits, and workload expectations to create a space where employees don’t just survive the workday but thrive in it. Taking proactive steps to reduce overstimulation isn’t just about productivity; it’s about creating a culture where employees can bring their best selves to work without the constant burden of mental overload.
Healthcare practitioners have no shortage of stress, and the job has some degree of overstimulation built in. However, reasonable steps can be taken to reduce overstimulation, and the changes will benefit both practitioners and the patients they care for.

### The Battle Against Workplace Noise
From drug-infusion pumps to heart-rate monitors to low-battery warnings to bed alarms firing off for routine body shifts, the number of alarms calling out to clinicians has skyrocketed in recent decades. Hospital audits have tallied hundreds of alarms per patient per day, most of them inconsequential or false. The resulting “alarm fatigue” not only contributes to clinician burnout but can degrade patient care, according to the American Association of Critical Care Nurses.
It’s a vicious cycle of noise, as each new alarm must get itself noticed above the prevailing din, and one of the big topics I cover in my book “Clamor: How Noise Took Over the World— And How We Can Take It Back” (Norton, May 2025). I zero in on the problem of signal overload and potential fixes in hospitals and elsewhere in the chapter, “All the Machines That All Go Beep.”
The chapter explores alarm management, technology solutions and quiet times. It also argues for paying closer attention to the sounds themselves, to make them more helpful and less distracting, which is part of the story (excerpted below).
Fighting Sonic Inertia
The battle against alarm fatigue is not simply about volume control but also about revamping hospital soundscapes to better support clinicians and patients. Momentum for this larger cause continues to build on multiple fronts.
Among those working to extricate hospitals from the noisy trap of their own making is Yoko Sen, a sound designer and composer of breathy ambient electronic music in New York City. About a decade ago, after an extended hospital stay, she co-founded Sen Sound with her husband. Through countless interviews and workshops with patients, clinicians and medical-device makers, Sen and her team encourage people to think expansively beyond the beeps, not only focusing on the hospital noises they want to escape but also considering how to create a better soundscape for healing.
During Sen’s hospitalization, she lay surrounded by machines beeping with unflagging urgency, and she thought about a neuroscience study she’d read, which suggested that hearing is the last sense to go before we die. Would this piercing chorus of beeps be her final sendoff? It seemed so tragic. At one point, an alert on her bedside monitor sounded so shrill and persistent that her husband flagged down a nurse for help.
“Oh, don’t worry,” the nurse reassured him. “That thing just beeps.”
Telling this story, Sen laughs at the notion of a machine that “just beeps,” without meaning or apparent purpose beyond sounding its unceasing electronic yawp. But the vignette also captures
the neglect of the wider soundscape that lies at the heart of alarm overload. Its cacophony is a result of the decades during which hospitals accumulated sound-emitting technologies with little regard to the mounting cognitive burden they might place on staff and patients. In 2018, for example, a lead product developer at Philips, a prominent medical device company, contacted Sen after watching a talk she gave and invited her to work with his team. He admitted that his company had largely ignored the alarm sounds their patient monitors made, despite devoting decades of engineering and countless dollars to research and development of the machines’ other aspects. Eventually, he traced the current alarm sounds to a cassette tape dating from 1981.
This is an example of “sonic inertia,” and it wasn’t surprising to Sen. Constant beeps might keep patients awake and anxious, and they might stress out busy nurses and doctors, but as long as they successfully snagged clinicians’ attention, they worked, and the sounds they made were left alone.
Sen’s first challenge, therefore, was to raise expectations of alarms beyond basic functionality.
Collaborating closely with the Philips product-design team, she played the company’s then-current alarm sounds to gatherings of doctors and nurses and asked, “If the patient monitor was a person, who would it be to you, based on these sounds?”
“A drill sergeant,” somebody said. Others suggested a dictator, an ignored boss, or a petulant toddler.
When asked what they might prefer, the clinicians said they wanted the monitor to sound more like a coach, a friend, or some other helpful and supportive person.
“I wish it to be a colleague,” one doctor ventured, “with the same interests as myself: to do what’s best for the patient.”
The next step was a series of virtual workshops to solicit broader thoughts on hospital alarms from both clinicians and laypeople in a dozen countries. The project team dissected the transcripts of these sessions, clustered common themes, and ultimately distilled eight criteria for a successful alarm. Half of them related to “functionality,” such as being simple to learn and locate in space, easy to distinguish amid background noise, and quick to stimulate a response. The other half were measures related to “sensibility,” including how startling, aggravating, fatiguing or distracting the current sounds were.
With these criteria as a guide, Sen Sound and Philips’s product designers started reworking the sounds for low-, medium- and high-priority alarms. Clinicians had said they wanted the low- and medium-priority alarms, which they heard most often, to be less aggressive, so the team slowed the pacing of the beeps and made them softer and “rounder,” more like chimes with lingering notes. Medium-priority alarms were distinguished from low-priority ones by making them a bit more percussive and higher pitched, “like a gentle tap on the shoulder.”
High-priority alarms kept the original pacing of beeps, but the timbre was tweaked to make it less shrill and harsh—clinicians said they wanted to be “warned without being jolted.”
The project team then gathered feedback via two rounds of online surveys embedded with sounds—first they tested a handful of alternative alarms against each other and then pitted the winning alternatives for low-priority, medium-priority, and high-priority alerts against the originals. They asked listeners to give their preferences and to rate the alarms on the eight criteria.
This led to a surprising discovery. Everybody had expected significant tradeoffs between functionality and sensibility. They assumed that the acoustic qualities that grab attention and prompt immediate action would be opposite in nature to those that make sounds softer, gentler, warmer or smoother. Yet survey respondents mostly ranked their preferred sounds higher in both functionality and sensibility. And they preferred the new sounds to the originals overall. Philips adopted the redesigned sounds in 2023.
Solutions to hospital noise that have staying power will move beyond squashing problem sounds and proactively consider the bigger sonic picture: soundscapes matter for healing.
As a coda to Sen’s time in the hospital, she composed a “final sound” mix of music and spoken word (recordings from people she’d ask to describe the final sounds they’d want to hear in this life).
The voices talked about the sounds of water as a source of life, a transformative force, or the reassurance of breaking waves reaching out from a vast, unfathomable ocean. Others spoke about hearing the voices and laughter of loved ones, a chorus of birds that could kindle a “feeling of the morning when I’m waking up to something new,” or simply a rhythmic beat strong enough to “carry me to whatever’s next.”
For nearly five minutes, the piece echoed with final sonic wishes.
Not one beep could be heard among them.

### TechTalk: Complex and Difficult
Flexible endoscopes are complex devices that can be difficult to clean, therefore facility personnel responsible for overseeing reprocessing of flexible endoscopes should review reprocessing practices several times a year and ensure that processing personnel are adhering to the instructions of the endoscope, processing equipment, detergent and cleaning-supply manufacturers.
Cleaning in healthcare facilities is defined as “the removal, usually with detergent and water, of adherent clinical soil (e.g., blood, protein substances, and other debris) from the surfaces, crevices, serrations, joints, and lumens of instruments, devices, and equipment by a manual or mechanical process that prepares the items for safe handling and/or further decontamination” (ANSI/AAMI ST91:2021, p.4).
The Occupational Safety and Health Administration (OSHA) defines decontamination as “the use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or disposal” (29 CFR 1910.1030[b]).
The decontamination process involves two steps. The first and most important step is manual and/or automated cleaning. The second step is the application of a chemical disinfection or sterilization process. Although this sounds simple, each step has many components that must be performed correctly to ensure effective processing and the safety and health of employees, patients and the community.
Cleaning, followed by thorough rinsing, is the first—and probably the most important—step in the decontamination process. Without thorough cleaning, items may not be completely decontaminated. Patient deaths and/or infections have been traced back to flexible endoscopes that were inadequately cleaned. Meticulously performing all steps required for cleaning flexible endoscopes, components and accessories is essential to ensure they are safe for patient use.
Cleaning and rinsing remove rather than kill microorganisms. If contaminants such as blood, body fluids and tissue are left behind after cleaning, they can prevent disinfecting and sterilizing agents from contacting all surfaces of the endoscope and possibly create a breeding ground for microorganisms, making disinfection more difficult. And remember: Just because something looks clean doesn’t mean it is clean.
Personnel responsible for cleaning flexible endoscopes must wear appropriate personal protective equipment (PPE) to prevent exposure to contaminants such as blood, body fluids and tissue, as well as pathogenic and nonpathogenic organisms. Reprocessing technicians work in a wet environment and are also working with potentially hazardous chemicals such as detergents and disinfectants. The recommended PPE includes a Level 4 barrier gown, face shield or goggles, a fluid-resistant face mask, decontamination gloves, headcover and fluid-resistant shoe covers, per ANSI/AAMI ST91:2021.
Principles of Cleaning
Designated facility personnel must ensure that the manufacturer’s instructions for processing every type of endoscope used in the facility are available and followed. It is important for endoscope-processing technicians to understand that regardless of the facility or the items being reprocessed, the fundamental principles of cleaning remain the same. Certain general principles of cleaning apply to all items being processed. These principles include the following:
 	The cleaning solution must contact every surface of the endoscope or endoscope accessory.
 	There must be some type of physical action, such as friction, which enhances the cleaning process. Friction is the action of one surface or object rubbing against another. Friction is created by scrubbing, brushing and rinsing all surfaces of the endoscope during manual cleaning and by flushing and rinsing detergent through the lumens of the device.
The following nine factors have an impact on cleaning.
 	Water quality
 	Water temperature
 	Cleaning activity of the detergents (also known as cleaning chemistry)
 	Mechanical action
 	Nature and design of the instruments or devices (e.g., simple or complex)
 	Type of soil (e.g., blood versus fatty soil)
 	Human factors/competence (e.g., training, complying with IFUs and using processing equipment correctly)
 	Cleaning verification (checking and documenting the effectiveness of the cleaning process)
 	Quality assurance (monitoring the cleaning process to ensure compliance with IFUs, facility policies and procedures, and applicable standards and guidelines)
When cleaning failures occur, one or more of these factors is involved.
It is important for all endoscope-processing team members to understand that disinfection and/or sterilization will not compensate for poor cleaning. The importance of performing adequate cleaning of flexible endoscopes cannot be overemphasized and is stressed in all professional guidelines and standards related to processing medical devices used for surgery and/or endoscopy. Further, the importance of obtaining and complying with the endoscope manufacturers’ IFU cannot be overstated.
The FDA had developed a guidance document, “Reprocessing Medical Devices in Health Care Settings: Validation Methods and Labeling Guidance for Industry and Food and Drug Administration Staff.” The purpose of this document was to guide medical-device manufacturers in creating and validating reprocessing instructions that, if followed, will ensure that their devices can be safely used for the purpose for which they were intended. Except for the specific regulatory or statutory requirements mentioned, this guidance document is not regulatory and is not legally enforceable; however, the IFU that manufacturers develop using this guidance document are recognized by the Joint Commission, AAMI, and other accreditation and professional organizations as providing a mechanism for the user to verify that the device can be safely reprocessed.
In addition to following manufacturers’ IFU, designated facility personnel must be able to verify the cleaning process recommended by a manufacturer. According to ANSI/AAMI ST58:2024, “Chemical Sterilization and High-Level Disinfection in Health Care Facilities (Annex N):” verification of a cleaning process consists of the following.
 	Visual inspection combined with other verification methods to determine the cleaning of the external surfaces and the internal housing and channels of medical devices
 	Testing the cleaning efficacy of cleaning equipment and
 	Monitoring key cleaning parameters (such as the temperature)
Manufacturers provide such tests so the equipment can be tested efficiently without damaging the devices or necessitating recleaning of the device.
Quality Improvement
Designated facility personnel should ensure that each step in the cleaning process is fully verifiable through personnel training and through observation and that the process can be followed completely, accurately and without variation by all individuals who perform it; they must also provide process controls along with validation and verification methodologies that ensure adequate, consistent cleaning levels.
To define any facility process, designated facility personnel must develop written policies and procedures that identify the steps of the process. The policies and procedures should be based on published professional guidelines and should align with the validated processes described in the manufacturers’ IFU.
Designated facility personnel must also ensure that each employee completes an orientation program wherein the employee receives documented education and training about the tasks they will be performing at the facility and that the employee undergoes documented competency verification demonstrating their ability to perform the tasks correctly. After successfully completing their orientation, designated facility personnel should continue to provide education and training of employees as needed and should verify the competencies of each employee at least annually—or more frequently, as needed.
All personnel processing flexible and semi-rigid endoscopes should be certified in flexible-endoscope processing within two years of employment and maintain their certification throughout their employment (ANSI/AAMI ST-91, 2021).
The importance of implementing an effective cleaning process is underscored by accreditation surveyors who have been instructed to request that endoscopy technicians obtain the manufacturer’s IFU for a particular endoscope and demonstrate and/or describe the process that should be used to clean the device. This enables the surveyors to evaluate whether the employee is following the correct procedure to ensure the cleanliness and safety of the endoscope.
The manufacturer’s IFU for each device should include information about the recommended cleaning and/or disinfecting agents, cleaning implements, and cleaning methods that should be used, as well as instructions about how to disassemble the device for effective cleaning, if applicable.
If a manufacturer’s IFU are unclear, inadequate or contraindicated by best-practice recommendations from relevant professional organizations, designated facility personnel should contact the manufacturer for additional information and clarification.
Any information obtained from a phone call with a manufacturer’s representative or from a manufacturer’s sales representative should be followed by a written statement from the manufacturer confirming the information. It is not acceptable to rely on verbal instructions. All device manufacturers’ IFU should be readily available to processing personnel for reference. Failure to comply with the manufacturer’s IFU could void the manufacturer’s expressed or implied warranty and could result in high-level disinfection or sterilization failures. It is the responsibility of the processing professional to comply with the manufacturer’s IFU.
Summary
There are many more steps in the cleaning process and each one is important. It is up to the facility to ensure that staff are thoroughly trained and competent in the cleaning process. Routine observations and audits should be performed to ensure compliance with state policies and compliance with the device manufacturer’s current instructions for use (IFU). Some personnel who are responsible for cleaning do not recognize the importance of their job.
It is important to understand that the process of high-evel disinfection depends upon the disinfectant reaching ALL surfaces and channels of the device. If the device is not cleaned per the IFU, the disinfection process could be reduced or even nullified. That is simply not acceptable. Although not glamorous, your job is critical to good patient outcomes. The patient depends on you to do the right thing.

### Antibiotic Resistance
Antimicrobial stewardship is an important mission for healthcare, a mission built on the “it takes a whole village” idea. Read on to see the big picture and how to contribute to the success of this global endeavor.
The Miracle Drug
Penicillin was discovered by Alexander Fleming in 1928. It was further developed for medicinal use by Drs. Howard Florey and Ernst Chain of Oxford University, just in time for treating soldiers in World War II. Penicillin was quickly dubbed a “miracle drug” and is considered one of the greatest contributions to health in the 20th century.
Penicillin bolstered human life expectancy by 27 years and allowed people more normal lives without the perpetual worry of common infections such as strep throat, pneumonia or sexually transmitted infections.
Undoubtedly, antibiotics like penicillin revolutionized healthcare and continue to save lives. However, with the near-indiscriminate use of the miracle drug—understandably fueled by vivid and morbid memories of overwhelming infections—antibiotic resistance followed on the coattails of overuse, complacency and misuse. This resistance threatened to diminish the progress made in the fight to control infectious diseases.
There is no single factor to blame for the development and expansion of antibiotic resistance. Rather, it was a combination of medical advances:
 	Overuse and misuse of antibiotics
 	A tremendous increase in the size of immunocompromised populations
 	A higher frequency of invasive medical procedures, longer hospital stays and more ICU days
 	Individuals with chronic debilitating conditions living longer
Science showed that resistance to antimicrobials was inevitable, but there are measures to slow this resistance, ideally to a more manageable pace. At the core of this endeavor is an essential need to understand and respect these drugs.
Antibiotic Resistance
An antibiotic is a selective poison, targeting bacterial cells and killing the pathogen while avoiding or minimizing damage to the human cells and human host. Different types of antibiotics affect different bacteria and act in different ways. For example, an antibiotic might inhibit the ability of the bacterium to turn glucose into energy, or by attacking its cell wall, as penicillin does. Penicillin attaches to a cell’s wall and destroys a key part of it, which causes the cytoplasm to spill out, killing the bacterium.
The antibiotic does not technically cause resistance but rather allows it to happen. This is an evolutionary process, and sometimes evolution is relatively rapid. Any population of microbes naturally includes variants with unique traits; these might include an ability to withstand an attack of the drug. (We learned that with COVID-19.)
When a patient takes an antibiotic, the drug kills defenseless bacteria and leaves behind those that resisted it. This is called “selecting.” The surviving bacteria then multiply, increasing their numbers a millionfold in a day, and the variant becomes the predominant microbe.
A patient can develop a drug-resistant infection, either by exposure to an already resistant microbe, or by creating a resistant microbe in their body once undergoing antibiotic treatment.
Pathogens resist antibiotics by interfering with the drug’s mechanism of action. Bacteria that survive an antibiotic assault can make changes in their own structure and pass the information to their “offspring.” Bacteria can also transfer genes by swapping DNA packets known as “plasmids.” In the healthcare environment where bacteria are challenged by antibiotics, genes that confer resistance become available to bacterial populations and create a perfect storm for resistance.
Stewardship
Resistance spreads fast, necessitating a plan to slow the pace, because there is no going back. The plan is a series of programs known as “antimicrobial stewardship.” Since these programs are used to control a variety of microbes (e.g., bacteria, yeasts, microscopic fungi) from developing resistance, “antimicrobial” is a preferred term (rather than antibiotic) to be more inclusive. “Stewardship” is a fitting word, as it implies responsibility in overseeing and protecting something worth caring for and preserving. The term also indicates positivity and comprehensive understanding of the microbes, the drugs, human behaviors, and alternatives to infection prevention.
The core elements of an antimicrobial stewardship program are accomplished by the entire community of health professionals and directed through healthcare organizations. Here’s the outline:
 	Prescribing and using antibiotics appropriately and only when necessary (for both humans and animals) by ensuring:
 	Antibiotics are prescribed only for confirmed bacterial infections and only when truly needed
 	The appropriate antibiotic is prescribed at the proper dose and for the proper duration
 	That prescribed antibiotics are used until the full antibiotic course is finished
 	Preventing infectious disease by:
 	Washing hands
 	Avoiding cross-contamination with appropriate personal protective equipment (PPE) when contact is unavoidable
 	Keeping current with vaccinations
 	Improving hygiene and sanitation
 	Promoting and monitoring infection prevention and control measures via surveillance and reporting to combat the misuse of antibiotics.
Prior Authorization
Some facilities restrict the use of certain antibiotics based on the spectrum of activity, cost or associated toxicities. Furthermore, some facilities ensure that intended use is reviewed by an antibiotic expert before therapy is initiated. This intervention requires availability of expertise in antibiotic use and infectious diseases, and its authorization needs to be completed in a timely manner. This function is managed by clinical pharmacists who can communicate directly with prescribing physicians.
Know Your Role
Nurses and technicians do not prescribe antimicrobial drugs, but they play a role in stewardship. Nurses can assure that cultures are performed before starting antibiotics. They also collect specimens for culture and therefore contribute to an accurate diagnosis. In addition, nurses review medications as part of their routine duties and can prompt discussions of antibiotic treatment, indication and duration.
Antibiotic “time-outs” are another key area in being a good steward. Antibiotics are often started empirically in hospitalized patients while diagnostic information is being obtained. However, providers often do not revisit the selection of the antibiotic after more clinical and laboratory data (including culture results) become available.
An antibiotic “time out” prompts a reassessment of the continuing need and choice of antibiotics when the clinical picture is more clear and more diagnostic information is available. All clinicians should perform a review of antibiotics 48 hours after they are initiated and answer these key questions:
 	Does this patient have an infection that will respond to antibiotics? If so, is the patient on the right antibiotic(s), dosage and route of administration?
 	Can a more targeted antibiotic be used to treat the infection (de-escalate)?
 	How long should the patient receive the antibiotic(s)?
Patient Education
Every facility or healthcare organization should have an antimicrobial stewardship program and should provide regular updates on antibiotic prescribing, antibiotic resistance, and infectious-disease management that address both national and local issues. Pay attention to these updates and any directives that include your role.
Nurses and pharmacists are responsible for educating patients and family members about the importance of the drug in treating the patient’s infection and the details of administration that will ensure effectiveness. Remind them not to save unused antibiotics for another time when they feel sick. Emphasize the importance of compliance and communication with their prescribing clinician if side effects threaten that compliance with the full course of the drug. Be sure to emphasize that antibiotics do not work on viruses like the common cold.
Please teach and train your family on these important matters, too. It takes a whole village to manage the challenge of antibiotic resistance.

### Taking Care of Each Other
Chelsea Hospital’s endoscopy team brings unique expertise to the table and a collaborative spirit that makes all the difference to their patients, according to Lindsey Quinn, RN, BNS, nurse coordinator.
“What truly sets our team apart is our unwavering commitment to excellence in patient care and our deep-rooted culture of support—for both our patients and one another,” Quinn said. “Despite being a relatively small team, we are mighty in our impact.”
The state-of-the-art facility in Chelsea, Michigan, is a joint venture between Trinity Health Michigan and U-M Health and features 16 pre-operative and post-anesthesia care-unit bays, two procedure rooms dedicated to pain management, and four fully equipped endoscopy suites. The staff includes 25 RNs, 12 per-diem RNs, two admin staffers, and seven surgical-care and instrument-care technicians.
In addition to outpatient services, the team also performs endoscopy and pain procedures for inpatients at Chelsea Hospital. The services include diagnostic and interventional procedures such as colonoscopies and esophagogastroduodenoscopies, dilations, banding, tattooing, cauterization, biopsies and snare polypectomies.
But at Chelsea, it isn’t just about the services. Quinn said, “Patient safety and well-being are at the heart of everything we do. We take great pride in the quality of care we provide, ensuring that every patient feels seen, heard, and supported throughout their experience with us.”
The core of that care is how the team takes care of each other.
“We are more than just colleagues,” Quinn said. “We are a work family. Many of us have walked through life’s highs and lows together, celebrating milestones and offering strength during difficult times.” This bond fosters a resilient, positive and supportive work environment that directly translates into better outcomes for the team’s patients.
Quinn’s colleague, Cara Olsen, RN, agreed. “Never have I worked with such a team that works so hard for the patient outcome and experience,” Olsen said. “As a team member you are loved the second you walk through the door. It’s a work family that is there for you in the good times and the bad. This is a rare find in work environments and what makes this team so great in my eyes.”
A few of the elements that make the team effective are the power of consistent communication, an ongoing mutual respect, and a shared commitment to both patient care and team well-being. “We believe that excellence in healthcare starts with a strong, connected team,” Olsen said.
Some best practices include:
Prioritizing patient safety and dignity in every interaction, no matter how routine the procedure may seem.
Maintaining open and honest communication through regular team meetings, daily huddles, and informal check-ins.
Fostering a culture of support and empathy, where team members feel safe to speak up, ask for help, and offer encouragement.
Celebrating wins—big and small—and recognizing each other’s contributions, which helps build morale and a sense of shared purpose.
Staying flexible and adaptable, especially during times of change or challenge, while always keeping patient care at the center of their focus.
Nicole Richardson, RN, has seen this firsthand. “Being in charge you see how much can change in a single day. Cases will be canceled, added, moved up in time slots, and moved locations. During these changes I get to see so many staff members step up, change assignments, and help others to get the job done.”
“Our philosophy is simple,” Quinn said. “When we take care of each other, we’re better equipped to take care of our patients. That mindset has helped us build a resilient, high-performing team that others can learn from.”
That’s not to say Chelsea Endoscopy doesn’t have its challenges. Quinn cited staffing shortages, increasing patient volumes and the far-reaching impacts of the COVID pandemic as some issues the team has had to sort through. “We’ve had to adapt quickly and work together to maintain the highest standards of patient care and safety,” she said.
The team has faced personal challenges, as well. Kimberly Hicks, RN, said part of the reason she loves her team members is because of the way they “come together when each other is navigating a difficult time in our lives. When it comes down to it, we are family and the support we give each other is beyond any other job I’ve ever had.
“What I love about our team is how we always pull together when things are crazy to provide the best care to our patients,” Hicks added. “Our patients would never know that it may be the worst day on the unit for staff because we mask it so well.”
Quinn agreed. “Through it all, we’ve remained a source of strength and support for one another,” she said. “Whether it’s covering shifts, offering a listening ear, or simply showing up with kindness, our team consistently demonstrates compassion not only for our patients, but for each other. These shared experiences have deepened our bond and reinforced our resilience. They’ve shaped us into a team that is not only highly skilled but also deeply empathetic and united by a genuine commitment to care—both within and beyond the walls of our department.”
This enthusiasm is shared by Denise Dembinski, RN, who said, “It’s good to work with people [who] are all committed to taking the best possible care of our patients. And also provide the best support for each other as we navigate life’s ups and downs.”
The team also celebrates achievements and milestones such as retirements, graduations and personal accomplishments— the things that make life rich and fulfilling. These celebrations often extend beyond work hours.
The team has gone on department outings such as renting a chauffeured bus to attend an event together, and they even went camping. In addition to social gatherings, the team holds monthly team meetings to stay connected professionally. These meetings provide a space to share updates, discuss improvements, and ensure everyone feels informed and valued. This ability to balance professionalism with genuine connection is a key part of what makes Chelsea’s work environment so positive and cohesive.
Quinn concluded, “Our exceptional teamwork, mutual respect and shared dedication make us not only effective but also proud of the work we do every day.”

### Under Threat
Medical journals are no strangers to receiving letters. However, one letter that arrived recently at several journals was extremely unusual. The letter was from the United States Department of Justice.
“We were surprised,” said Dr. Eric Rubin, editor-in-chief of The New England Journal of Medicine, in an interview with National Public Radio (NPR). Rubin said the letter came from a U.S. attorney for the District of Columbia.
According to NPR, the letter asked about “misinformation, competing viewpoints and the influence of funders such as advertisers and the National Institutes of Health.” Such letters were also sent to JAMA, Obstetrics & Gynecology, CHEST, and possibly others. “The public has certain expectations, and you have certain responsibilities,” the letter added, with a request for response by May 2. The letter mentioned that the journal has tax-exempt status.
“It does feel like there’s a threatening tone to the letter, and it is trying to intimidate us,” Rubin told NPR. “We were concerned because there were questions that suggested that we may be biased in the research we report. We aren’t. We have a very rigorous review process. We use outside experts. We have internal editors who are experts in their fields as well. And we spend a lot of time choosing the right articles to publish and trying to get the message right. We think we’re an antidote for misinformation.”
I find it very concerning that government agencies would attempt to influence or intimidate medical publications through threatening correspondence. Such actions set a dangerous precedent and compromise the objective evaluation of healthcare interventions, treatments and policies. The staffs of medical journals ensure that research meets rigorous standards of methodology, peer review, and ethical conduct—there’s no need for government agencies to pollute this process.
The peer-review system exists precisely to insulate scientific evaluation from external pressures, whether political, commercial, or ideological. It’s not a perfect process, and there have been troubling incidents over time, but these instances are few and far between. We can trust the vast majority of research printed in reputable journals. In these publications, editors and reviewers assess research based on methodological rigor, statistical validity, and contribution to medical knowledge—not on whether findings align with any current political preferences. This independence has enabled medical science to advance treatments for cancer, develop vaccines that have saved millions of lives, and establish safety protocols that protect patients worldwide.
Government threats, such as the aforementioned letters, may chill the research environment itself. Scientists may become reluctant to pursue research or report findings that could attract government scrutiny. Yes, government agencies often have legitimate interest in understanding research findings, but feedback should be shared through appropriate channels such as public-comment periods, advisory committees, and transparent regulatory processes—not through an effort to intimidate publishers.
I hope the medical journals contacted by the DOJ will continue to resist pressure. I imagine they will. Patient lives, public health, and the integrity of American medical science all depend on maintaining the independence that has made American medical journals among the most respected and influential in the world. The leaders of such journals deserve our trust and support.
In far less controversial news (although somewhat related, since we’ve essentially been discussing boundaries), I hope you’ll enjoy our cover story about setting boundaries at work. This piece explores relationships with sometimes-difficult colleagues, bosses and patients. That topic is accompanied by articles that tackle setting boundaries with a different challenge: noise and distractions. This package begins on page 18. Lastly, you’ll see a familiar name in one of our editorial departments this issue. Our longtime Infection Prevention Now author Nancy Haberstich’s column is filling in for AfterCare’s Patricia Raymond while she’s on break. Nancy’s column is about antibiotic resistance. I wish this topic weren’t still relevant, but unfortunately, it is. You can find the column on page 28.

### PhD in Health AI Program Earns Accreditation
The newly established PhD in Health Artificial Intelligence (AI) program in Cedars-Sinai’s Health Sciences University has earned accreditation from the Senior College and University Commission of the Western Association of Schools and Colleges.
The PhD in Health AI program is the first in the United States to be embedded in a hospital and the first to combine interdisciplinary academic training with hands-on clinical data experience, giving students opportunities to develop AI solutions that could improve diagnostics, patient care and healthcare delivery.
“Accreditation is a meaningful milestone for the PhD in Health AI program,” said Graciela Gonzalez-Hernandez, PhD, director of the program and professor and vice chair for Research and Education in the Department of Computational Biomedicine. “It signifies that the highest standards of academic excellence and innovation are at the heart of our curriculum, and it signals to prospective students, as well as our faculty and partners, that we’re pioneering a new kind of doctoral training with quality and rigor.”
In their report, commission evaluators praised the program for integrating doctoral-level learning into real-world work experiences and for offering extensive academic resources and support services for students’ coursework and research.
“Our Health Sciences University continues to evolve, with our newest PhD program enabling us to train the next generation of AI experts specifically focused on healthcare,” said Jeffrey Golden, MD, executive vice dean of Research and Education, director of the Burns and Allen Research Institute, and the Linda and Jim Lippman Distinguished Chair in Academic Medicine at Cedars-Sinai. “As AI is poised to rapidly transform medicine, accreditation for the PhD in Health AI program helps further reflect and reinforce our commitment to shaping the future of healthcare.”
The PhD in Health AI program aims to attract applicants from diverse fields beyond healthcare, including computer science, engineering, math and gaming. Through an active-learning and structured mentoring model, students will gain exposure to real-world clinical environments and collaborate closely with clinicians and scientific investigators.
In addition to laboratory rotations with Cedars-Sinai’s AI research faculty, the program also includes clinical rotations—rare for nonmedical PhD students—to help participants understand how clinical information is generated and used.
“We look forward to welcoming our first cohort of exceptional students this week—each with a strong technical background and a shared commitment to improving healthcare,” Gonzalez-Hernandez said. “Throughout their time at Cedars-Sinai Health Sciences University they will engage with faculty, clinicians and each other to meaningfully and ethically apply AI in real clinical settings. They will graduate with a deep understanding of real-world healthcare challenges, positioning them for successful careers in academic research, industry, healthcare innovation, and public policy.”
Cedars-Sinai’s Health Sciences University was established in 2024. The university offers other graduate degrees, including a PhD in Biomedical Sciences, Master of Science in Health Systems and Master of Science in Magnetic Resonance in Medicine.
The university also is home to several professional training programs, including nondegree educational certifications, formal trainings, internships and other ongoing opportunities to benefit students and professionals at all career levels.

### Study: Coffee Does Not Increase Risk of Diverticulosis
According to a recent study in the publication BMC Gastroenterology, for patients undergoing colonoscopy, coffee or caffeine intake was not associated with a higher risk for colonic diverticulosis.
The study can be found here. Further research may explore whether different coffee types have varying effects.
Diverticulosis is the most common benign pathology of the colon. Genetics, inflammation, neuromuscular abnormalities, colonic motility and lifestyle including dietary habits play roles in disease pathogenesis, according to the study abstract.
“Coffee is one of the most commonly consumed beverages worldwide and exerts anti-inflammatory functions in the human body as well as affecting colonic motility and neuromuscular physiology of the gastrointestinal system,” the study continued. “Therefore, this study was planned to investigate the relationship between coffee consumption and diverticulosis.”

### Olympus and Partner Launch Swan EndoSurgical
TOKYO—Olympus Corporation recently announced an agreement with Revival Healthcare Capital to drive advancements in endoluminal robotics. Olympus and Revival will co-found Swan EndoSurgical, a new company dedicated to developing a novel robotic system designed to revolutionize gastrointestinal patient care in the future.
Endoluminal robotics aims to empower more physicians to safely perform innovative techniques, enhancing patient access to treatment options that support safety and improved recovery times. This advancement has the potential to create new and significantly enhanced minimally invasive treatment options for major unmet medical needs by boosting precision and efficiency in procedures addressing ergonomic strain for healthcare professionals.
Bob White, president and CEO at Olympus, said, “This partnership marks a significant milestone in our strategic initiative to advance endoluminal robotics. We are excited to enter this collaboration that we expect to play a pivotal role in reshaping the GI market by expanding procedural capabilities for physicians. This will allow the delivery of transformative, organ-sparing care that enhances outcomes for a broad patient population.”
For decades, endoscopy has yielded early and accurate diagnoses of conditions such as GI tract cancer. In recent years, specialists, primarily gastroenterologists, have begun performing endoscopic therapeutic procedures, such as cancer resection, by inserting instruments through the endoscope. However, manual endoscopes and their instruments have limitations that make many advanced procedures within the lumen of the GI tract challenging and not widely available globally.
The development of an endoluminal robot, with its ability to easily maneuver within the GI tract and deploy flexible arms, provides the opportunity for more patients to benefit from safe and effective procedures, potentially avoiding invasive surgery. This innovation allows for the early, safe, and effective treatment of lesions or tumors in the GI tract relative to current therapeutic options. Furthermore, the technology has the potential for application in numerous other disease areas.
Headquartered in the United States, Swan EndoSurgical has assembled a leadership team of highly experienced industry professionals who will drive technical, clinical, and commercial development of the robotic platform. Swan is focused on the development of endoluminal surgical robotics with the aim to create effective treatment of lesions or tumors in the GI tract relative to current therapeutic options.
 
 

### AMA Expresses ‘Deep Concern’ About RFK’s Gutting of Task Force
CHICAGO–The American Medical Association (AMA) in late July expressed “deep concern” to U.S. Health and Human Services Secretary Robert F. Kennedy about news that he intends to remove all members of the U.S. Preventive Services Task Force (USPSTF).
“USPSTF plays a critical, non-partisan role in guiding physicians’ efforts to prevent disease and improve the health of patients by helping to ensure access to evidence-based clinical preventive services,” the AMA said in its letter. “As such, we urge you to retain the previously appointed members of the USPSTF and commit to the long-standing process of regular meetings to ensure their important work can continue without interruption.”
The full letter reads as follows:
Dear Secretary Kennedy,
On behalf of the physician and medical student members of the American Medical Association (AMA), I am writing to express our deep concern with the recent reports of your intention to remove all of the members of the United States Preventive Services Task Force (USPSTF). As you know, USPSTF plays a critical, non-partisan role in guiding physicians’ efforts to prevent disease and improve the health of patients by helping to ensure access to evidence-based clinical preventive services. As such, we urge you to retain the previously appointed members of the USPSTF and commit to the long-standing process of regular meetings to ensure their important work can continue without interruption.
The USPSTF has long played an essential role in making evidence-based recommendations for clinical prevention of disease. USPSTF members have been selected through an open, public nomination process and are nationally recognized experts in primary care, prevention and evidence-based medicine. They serve on a volunteer basis, dedicating their time to help reduce disease and improve the health of all Americans—a mission well-aligned with the Make America Healthy Again initiative.
Importantly, the USPSTF puts forth recommendations that dictate coverage policy for health insurers nationwide. By law, insurers must cover USPSTF-recommended services without cost sharing. This means that patients have access to services such as screenings for colon, breast, and lung cancer; screenings for anxiety and depression in children; and screenings and preventive services for cardiovascular disease. Access to these services without cost sharing plays a critical role in keeping patients healthy and reducing the burdens of disease.
The most important role physicians play is improving the health of patients. Given the essential role USPSTF members play in weighing the benefits and harms of preventive services such as screenings, behavioral counseling, and preventive medications, and making evidence-based recommendations for implementation in primary care settings, we urge you to keep the previously appointed USPSTF members and continue the task force’s regular meeting schedule to ensure recommendations are put forth, updated, and disseminated without delay."
 

### COVID Pandemic Linked to Surge in Digestive Disorders
A study led by Cedars-Sinai investigators uncovered a significant uptick in chronic digestive disorders, like irritable bowel syndrome, during the COVID-19 pandemic. The study findings, published in the peer-reviewed journal Neurogastroenterology & Motility, highlight a potential link between pandemic-related stress on the gut-brain axis.
“Using data from a national online study, we found that rates of digestive issues such as irritable bowel syndrome and chronic idiopathic constipation rose significantly,” said Christopher V. Almario, MD, MSHPM, lead author and gastroenterologist at Cedars-Sinai. “These findings underscore the significant toll the pandemic has taken on digestive health.”
Also known as disorders of gut-brain interaction, conditions like irritable bowel syndrome and chronic idiopathic constipation are common gastrointestinal disorders driven by complex interactions between the gut and nervous system.
Nearly 40% of people in the U.S. are estimated to meet diagnostic criteria for at least one disorders of gut-brain interaction, making these conditions a major source of healthcare burden and reduced quality of life.
“These disorders involve chronic gastrointestinal symptoms that are often triggered or worsened by psychological stress,” said Almario.
To better understand how the viral infection might be linked with digestive health, researchers analyzed data from over 160,000 adults across the U.S. who participated in a national online survey conducted from May 2020 to May 2022.
Participants completed detailed questionnaires covering digestive symptoms, mental health and lifestyle changes. By tracking responses over time, the researchers observed a steady rise in gut-related health issues that began early in the pandemic and persisted throughout the survey period.
Key findings showed that rates of irritable bowel syndrome increased from around 6% among U.S. adults in May 2020 to about 11% in May 2022. Chronic idiopathic constipation rose slightly from 6.0% to 6.4%. Among adults who reported IBS, investigators noted that the prevalence of mixed IBS, a subtype of IBS where a person experiences both diarrhea and constipation, was most commonly reported. The investigators did not observe significant increases in other types of functional digestive disorders.
As doctors uncover the long-term health effects of COVID-19, study investigators hope this study may draw attention to how the virus’ impact on mental health may affect the gut—potentially triggering or worsening disorders like IBS and other gut-brain conditions.
“This research calls for a renewed focus on gastrointestinal health in the post-pandemic era,” said Brennan Spiegel, MD, MSHS, corresponding author of the study and director of Health Services Research for Cedars-Sinai.
Spiegel, director of the Cedars-Sinai Master's Degree Program in Health Delivery Science and the George and Dorothy Gourrich Chair in Digital Health Ethics, says even those who did not get COVID-19 but endured significant psychological distress also may have had alterations in their gut-brain axis.
“Healthcare providers must be vigilant in recognizing and addressing the long-term effects of the pandemic on digestive health,” said Spiegel.

### Online Course Offers Gastro Education Credits
The American Gastroenterological Association, in partnership with Clinical Care Options, LLC, and with support from an independent educational grant from Merck & Co., Inc., Rahway, NJ, USA, invites you to explore the latest in inflammatory bowel disease (IBD) care through the module: “Advancing Inflammatory Bowel Disease Management with Precision Medicine and Emerging Data.”
This educational activity is designed for gastroenterology professionals such as physicians (residents and fellows), nurse practitioners, and physician associates, who are committed to staying at the forefront of IBD treatment.
IBD, encompassing Crohn’s disease and ulcerative colitis, affects more than 2 million in the U.S. and presents ongoing challenges in achieving sustained remission. With the rise of treat-to-target strategies, the focus has shifted toward deep remission, biomarker normalization, and mucosal healing—goals that demand precision and personalization in care.
This module delivers insights into:
 	Emerging biomarkers and diagnostics that guide individualized therapy
 	Role of biomarkers and treat-to-target approaches in IBD
 	Novel targets such as TL1A blockade with antifibrotic potential
Upon completion, learners will be able to:
 	Detail available and emerging biomarkers and diagnostics informing treatment decisions in IBD
 	Incorporate biomarkers into clinical practice based on guidelines and expert consensus
 	Evaluate evidence for the utility of TL1A blockade in IBD treatment
Meet the Faculty:
Jordan E. Axelrad, MD, MPH, FACG
Co-Director, Inflammatory Bowel Disease Center at NYU Langone Health
Associate professor of medicine
NYU Grossman School of Medicine, New York, N.Y.
Dr. Axelrad brings deep clinical expertise and research insight into the evolving IBD landscape, offering learners a practical and evidence-based perspective on precision medicine.
Participants can earn:
0.75 AMA PRA Category 1 Credit™ (Physicians)
0.75 AAPA Category 1 CME credit (Physician Assistants/Associates)
0.75 Nursing contact hour (Nurse Practitioners/Nurses)
For more information, click here.

### German Study Explores Endoscopy Waste
A multicenter observational study from the German healthcare system suggested that the annual waste generated by endoscopy in hospitals and outpatient settings in the country is roughly equivalent to the waste produced by a small town. The study details follow.
Background: Endoscopic procedures are a notable source of medical waste, contributing significantly to environmental pollution. Prior studies report 0.5–3.0 kg of waste per procedure—compared with just 1.2 kg of household waste generated per person per day in Germany.
Objective: To quantify endoscopic waste in hospitals and outpatient settings, assess its impact on the healthcare system and identify strategies for reduction.
Design: This prospective, multicenter, observational study was conducted over four weeks in two tertiary hospitals and two gastroenterology offices. Waste from 2,275 patients across 2889 procedures was collected, sorted, weighed and categorized for recyclability. National waste generation from GI endoscopy was estimated using published insurance data.
Results: The average waste per procedure was 1,119 g (hospitals: 1167 g; offices: 1094 g). Office-based procedures produced significantly less waste than their hospital counterparts—by 51% for esophagogastroduodenoscopy (EGD), 50% for colonoscopy, 47% for combined procedures and 69% for sigmoidoscopy (all p<0.001). Performing consecutive procedures reduced waste by up to 39% for EGD and colonoscopy, and 33% for endoscopic ultrasound and endoscopic retrograde cholangiopancreatography.
Switching from single-use to reusable gowns could reduce personal protective equipment waste by 54%. Overall, 23% of waste was potentially recyclable. Nationally, GI endoscopy generates an estimated 8024 tons of waste annually—equivalent to the yearly household waste of 18, 533 German citizens.
Conclusion: The waste generated by endoscopy per year in Germany rivals that of a small town. Adopting targeted waste reduction strategies—focusing on prevention, reduction, reuse, recycling and recovery—can substantially mitigate the environmental footprint of endoscopic practice.
 

### Interviewing Patients
A patient just walked in and gave you that laundry list of issues. You might become frustrated and think, “Where do I start with all the information?”
I’ve been having diarrhea for the past few days. I’m always in the bathroom. All the bathroom trips are so difficult because something is wrong with my one knee. I also feel queasy. While this is going on my heart is racing, maybe because of my nerves. I also have a lingering cough. Did I mention my jaw hurts?
This article will provide top strategies to help you gather and organize information in a timely fashion while still maintaining rapport and efficiency.
Rapport Before Report
Outside of emergency situations, first briefly focus on the emotional aspects of a patient’s experience and then move to the medical part. This action will assist you as prepare to gather patient information. This process puts the patient at ease, and they are more likely to be friendly and forthcoming with all information.
If the patient you are speaking with mentions their abdominal pain is making it hard for them to focus on their responsibilities in the workplace, it would seem logical to immediately ask about their symptoms. Stop. This person is having medical issues, but they are also describing strong emotions.
Instead of immediately asking about the symptoms, first use empathy. For example, you can say, “That must be very challenging.” The patient now knows you care about them and what to help. Now you are ready to ask about the medical issues. Unfortunately, many healthcare professionals bypass the emotional issues and go right to the medical situation. This leads the patient to think, “This person doesn’t care about me.”
The reason empathy works is because it leads to trust. Patients who feel trust in their healthcare team are more likely to be compliant—and hence have better outcomes. Let’s say two of your colleagues gave you advice: One colleague you trust, and the other you are not too sure about. Whose advice are you more likely to follow? Of course, the person you trust.
If a patient is asymptomatic, there are still ways to connect emotionally to enhance the interviewing process. In your electronic medical records, note the hobbies and interests of patients. In this way, when they walk in the door you can ask about their garden or favorite sports team. You put them in a good mood and that makes for a much more pleasant interview. My wife and I live with a houseful of pug dogs. When I walk into my dentist’s office, the first thing they say is, “How are the pugs?” I am immediately in a wonderful mood.
Opening Line
Asymptomatic patient: If the patient is not experiencing any issues, such as a person having a screening colonoscopy, then the opening line could be a simple, “Hello.” Outside of general updates regarding their health and medications, a friendly welcome works fine.
Symptomatic patient: First of all, do not say, “How are you?” to a symptomatic patient. This may seem odd and counterintuitive, but there is a reason to avoid this question. According to John Tongue, M.D., chair of the American Academy of Orthopedic Surgeons Communications Skills Project Team, “In the U.S., this is a greeting, not a question, that can put the ill or injured person in the awkward position of saying they are ‘fine,’ just before telling you their story or problem(s).”
Start with an open-ended statement or question, such as, “Tell me what is going on,” or “How can I help you today?” I used to ask patients, “What brought you here today?” but stopped after a patient responded by saying, “The bus.”
If you know a patient is coming in with a specific complaint, start with a general question anyway. This action is recommended in case the patient has a hidden agenda. The complaint they have on the phone may not be the real issue. After the patient states their chief complaint, do not yet ask for details until you ask these two words, “What else?” Asking these two important words will get all the issues out in open and avoid the dreaded, end-of-meeting, “Oh, by the way...” issues. You don’t want the patient to drop a bombshell just as you are about to walk out the door.
Nonverbal Factors
The patient: While asking the patient questions, look at their body language. Are you seeing any discrepancies? Does the patient say they do not feel stressed, but you notice their legs are trembling? Actions speak louder than words. Patients could say one thing, but the body movements tell the real story.
The professional: During the interview, look at the patient. Eye contact is a critical to tell the patient you are with them as they share their story. Based on the physical setup of the medical environment, sometimes eye contact may be challenging, such as when the patient is at a ninety-degree angle. However, on occasion, turn and look at the patient.
If possible, sit down so you are at the same level, eye to eye. Sitting sends the message, “I have time for you.” Patients perceive you are with them for longer periods of time when you sit. If you have one quick question for a patient, sitting is not necessary, but if the interview will be lengthier, have a seat.
Be Patient
Leana Wen, M.D., is the co-author of the book, “When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests.” The book is for patients on how to have more effective interactions with healthcare professionals. However, her strategy to help patients is something every healthcare professional must understand. Wen tells patients, “You can’t just give symptoms; you have to give your story.”
When interviewing patients, focus on their story, not individual symptoms. A series of disjointed symptoms may be hard to piece together, but a story in chronological order can solve the mystery.
Healthcare professionals are often so focused on symptoms, they lose sight of the story, or “the big picture.” We must allow patients time to speak without being interrupted so they have sufficient time to tell their story. The type of questioning seen below could be problematic:
Patient: “My belly hurts.”
Professional: “Is the pain worse on the right or left?” Patient: “The right, and—”
Professionals: “Is the pain worse when you sit or stand?”
When we constantly interrupt patients, we may miss the story and may miss the real medical issue. In addition, it’s simply rude. Instead, ask an open question and let them tell their story with an occasional “Go on,” or “Tell me more,” sprinkled in the conversation. Once you have heard the entire story, then you are ready to ask the specific details.
I am a firm believer in this story process because I was misdiagnosed for over a decade due to no one giving me the time to share my story. About 20 years ago, I began having sinus headaches. I visited my family doctor’s office and was told to try over-the-counter medications. The meds didn’t help, so I returned to the office. I was then told I had an infection and was put on antibiotics. After taking a course of antibiotics, I had no symptom relief.
Next, my family doctor referred to an allergist, who discovered I had an allergy to molds. We thought we found the answer to my problem. I was put on allergy shots. After two years, my headaches got worse. I stopped the allergy shots and for years spoke to different healthcare professionals.
My family doctor then suggested trying the allergy route again with a new allergist. The new allergist’s style of interviewing was dramatically different than everyone else I spoke with during my struggle to get answers. She said, “Tell me about your headaches,” and she let me talk with no interruptions except for an occasional, “Go on.”
The other professionals I saw would constantly interrupt with questions about my specific symptoms. While she let me talk, I revealed that when the headaches got bad, I would feel nauseated and sometimes vomit. After I was done telling my story, she stated, “No allergy testing will be done today. You don’t have sinus headaches, you have migraines.” I was misdiagnosed for years because no one gave me the chance to tell my story, as they were too busy focusing on individual symptoms. I wasn’t closed off to discussing the GI symptoms; I simply was never allowed to talk long enough to reveal them.
The best way to get to the story is ask an open question, stop talking, and start listening.
Too Many Issues, Not Enough Time
The example used at the beginning of this article (in which a patient has a large list of issues to discuss) must be handled in a thoughtful manner. We want to maintain an excellent patient experience but also manage all the medical issues. There is right way and wrong way to handle this situation. Below are examples of a harsh inappropriate response and a sensitive helpful response.
Ineffective response: “We don’t have time to discuss all those issues.” This response results in the patient feeling angry. This response doesn’t set the stage for a productive interview since we started in a negative manner.
Effective Response: “I wish we had time to discuss everything today. How about if we discuss these two issues: ______ and ______. We’ll schedule another appointment for the other issues. How does that sound to you?” This response is friendly and creates a wonderful experience for the patient. This response also highlights shared decision-making, since you asked the patient their thoughts on your suggested course of action.
Avoid “Why” Questions
Using the word “why” can often be seen as judgmental and should be avoided. This will make the question seem much harsher for the patient, rather than putting them at ease.
Think about the questions you heard growing up (at least, I heard them as a kid): “Why is your room so messy?” and “Why didn’t you eat your vegetables?” These questions are toxic because they come across as accusatory, and since the healthcare environment is a therapeutic milieu, we should create a comfortable place for patients.
Converting “why” questions to “what” questions creates a friendly feel to the interview. Here are examples:
"Why" question: “Why did you stop wearing your support stockings?”
"What" question: “What was happening that led you to stop wearing your su
pport stockings?”
"Why" question: “Why did you stop taking your medication?”
"What" question: “What could we do to get this medication back in your life?”
“Why” questions should also be avoided when talking to colleagues, family members and friends. These types of questions make everyone feel defensive.
Use “I” Language, Not “You” Language
Using the word “you” is verbally pointing your finger at the patient. During the interview, if the patient states they were not compliant or engaged in unhealthy activities, do not use “you” language. The example below will clarify the vast benefits of “I” language in these situations.
An example of a diabetic patient who admits to not being compliant with their diet.
“You” statement: “You have to watch your diet.”
“I” statement: “I want to help you. I want you to feel better. Let’s talk about your diet.”
The “you” example sounded harsh, while the “I” example sounded caring.
To enhance your interviewing skills even more, combine “you” language with “non-why” questions, and you’ve got a winning strategy.
Family Dynamics
Focusing on the patient, ignoring the family: I have observed thousands of healthcare professionals interacting with patients. In many cases, I have seen the professional walk in and immediately start speaking to the patient—but completely disregard the family members or friends in the room. This is a problem for many reasons.
First of all, you want to be sure the family members also have a good experience. In addition, the family members can add to the story as you ask questions. Yes, direct your questions to the patient, but also be sure to let family members know they can add to the discussion. Family members are your allies.
When it comes to focusing on the family but ignoring the patient, just because a person is older doesn’t mean they can’t answer questions. I recall many times when I would take my mother to a medical appointment, the healthcare professional would look at me and say, “How is she doing?” My mother wasn’t having any cognitive issues and would feel very frustrated that the questions were being directed at me. If the patient is cognitively aware, ask them the questions.
Summarize the Patient’s Story
After the patient has shared their story, briefly review the story to be sure you have all the facts in chronological order. This is a very important process. In this way, you can verify you have not missed any important details.
Smoothly flowing interviews help keep patients satisfied and safe. They also help professionals, too. By following the tips in this article, you’ll be more productive and feel less stressed.

### Anal Cancer Rising Among Older White and Hispanic Women
BETHESDA, Maryland— Anal cancer has been steadily increasing in the United States, with the biggest jumps among older women, especially white and Hispanic women—a shift that challenges assumptions about high-risk groups and who should be screened.
“Rates of anal cancer are rising fastest among white and Hispanic women over 65—groups not traditionally considered high risk,” said lead author Ashley Robinson, MD, a second-year internal medicine resident at Advocate Lutheran General Hospital. “While the exact reasons behind this trend remain unclear, most older women were beyond the recommended age for human papillomavirus vaccination when it first became widely available.”
Human papillomavirus, known as HPV, causes 90% of anal cancers.
Researchers analyzed data from the National Cancer Institute’s Surveillance, Epidemiology, and End Results database, known as SEER, from 2017 to 2021. They found anal cancer increased by 2.9% for women and 1.6% for men. Anal cancers increased fastest among white women over 65, who saw a 4.3% increase during the five-year study period, reaching 11.4 cases per 100,000 in 2021. If the trend continues, the incidence of anal cancer in women over age 65 would double in less than 17 years.
Hispanic women over age 65 had the second-highest rate of anal cancer, with 7.5 cases per 100,000 people in 2021 and a slower annual increase of 1.7%.
“It’s crucial that we promote HPV vaccination as a key tool for preventing anal cancer, while also keeping health care providers informed as screening guidelines evolve,” Dr. Robinson said. “These findings highlight specific patient groups who may benefit from targeted screening for anal HPV and anal cancer.”
Still considered rare, anal cancer makes up approximately 1% of all gastrointestinal cancers, with more than 90% of cases linked to chronic HPV infection. While screening for anal HPV, dysplasia and cancer is recommended for high-risk groups—identified as individuals with HIV, bone-marrow-transplant recipients and other immunocompromised populations—older women addressed in this study are not included.

### New Companies, New Products
We’re all familiar with the most massive, long-standing companies that are bedrocks of the endoscopy and processing industries, and we’re familiar with some smaller names that have been around a long time too. Anyone who has been to an endoscopy or processing tradeshow has grown accustomed to the giant booths that anchor even massive floor spaces. The endoscopy and processing industries are quite stable with these mainstay companies, but those companies do continue to roll out new products that you might not be familiar with, and new companies pop up as well.
Thus, a primer.
The following article highlights a smattering of those new products, new companies and some new(ish) companies. Everyone gets used to certain providers and products, but it’s always great to check into unknown sources and products. There are many fresh choices to consider. Indeed, the endoscopy market is witnessing a surge of new companies leveraging robotics, artificial intelligence, advanced imaging, and miniaturization to enhance diagnostic and therapeutic capabilities. These innovations aim to improve patient outcomes, reduce procedure times and expand the scope (pun intended?) of minimally invasive procedures.
For instance, companies like EndoAI are developing AI-powered software with the goal of assisting endoscopists in real-time identification of polyps, tumors and other abnormalities, improving early detection rates and reducing oversight. Below, you’ll first see new and newish companies, and below that you’ll find a smattering of new products. The new-products list is in no way exhaustive—products are being launched all the time.
Arithmedics
Arithmedics, founded in 2023, uses generative AI and data intelligence to streamline billing and reduce claim denials. Its software generates and explains codes and uses data from completed claims to reduce future denials.
According to the company, “We are redefining healthcare administration with AI—building leaner, faster, smarter systems that restore physician time for patient care.”
Arithmedics is based in Cupertino, California.
Aspero Medical
The leaders of Aspero Medical seek to advance flexible endoscopy with their Pillar balloon overtube solution. The balloon overtube is designed to improve mucosal-wall traction and anchoring consistency in the GI tract, while also providing atraumatic engagement with the bowel wall.
Aspero Medical is based in Boulder, Colorado and was founded in 2018.
Aurora Medical Technologies
Cofounded by gastroenterologists in 2021 and based in Minneapolis, Aurora Medical Technologies strives to make endoscopic suturing easier for surgeons. Aurora has developed a minimally invasive suturing technology using through-the-channel, multipuncture, reloadable tissue-anchoring systems.
The technology can be used on complex endoscopic procedures, such as gastric remodeling for obesity, gallbladder drainage, closure of luminal defects and facilitation of gastroenteric anastomosis.
Endiatx
The medical device startup Endiatx launched in 2019 and is based in Hayward, California. Endiatx offers PillBot, a series of pill-sized robots for remote diagnosis within the GI tract.
Company literature states, “We gave our pill camera motors to make it maneuverable, and we made it affordable enough to flush down the toilet. No anesthesia or pre-op visits, just 10 minutes of real-time video from the inside.”
Ergami Endoscopy
Ergami, based in Brooklyn, New York, is developing what the company calls a “low-cost” robotic colonoscope insertion solution to improve procedure productivity.
Company literature says that the product will also reduce patient pain and need for sedation and can lower endoscopy-related injuries in endoscopy professionals. Ergami launched in 2023.
Lazurite
Lazurite was founded in 2015 in Cleveland, Ohio and was formerly known as Indago. Lazurite’s ArthroFree2 allows users to “experience a crystal clear, crisp image with Meridiem image enhancement,” according to Lazurite marketing materials. “As your camera hand guides your vision, complete your procedures with unparalleled focus and efficiency.”
According to the American Gastroenterological Association, the Lazurite wireless surgical camera system “improves operating room safety and efficiency by allowing surgeons to perform endoscopic, arthroscopic, and other minimally invasive procedures without light or video cables. The cordless camera provides high-quality images while eliminating trip, fire and contamination hazards and removing ergonomic challenges caused by tethering.”
Xenocor
The company Xenocor launched about a decade ago and is based in Salt Lake City, Utah. Xenocor designs, develops and produces single-use laparoscopes, such as the Saberscope. According to Xenocor marketing materials, Saberscope is the “only laparoscope with an industry-first 1080 HD single-use camera.” Other product details state that the Saberscope is fog-free and:
 	articulates 90°
 	has improved visualization in smoky cases
 	limits burn
 	reduces delays and cancellations
 	reduces cross-contamination risk
SteriView Technologies
SteriView Technologies offers an infection-control system that enables direct visual inspection of hard-to-reach spaces in endoscopes and related medical devices.
According to SteriView’s CEO, Jerry Katzman, M.D., “The SteriView Infection Control System featuring the SteriCam line of inspection cameras represents the next inventive step and comprises a most critical asset in the fight against healthcare-associated, device-related infections.”
SteriView launched in 2016 and has its research and development housed in Petaluma, California with its engineering and manufacturing in Northvale, New Jersey.
 
NEW PRODUCTS
Cloud Endoscopy System
NTT and Olympus announced in late March that the two companies have jointly begun a demonstration experiment of a cloud endoscopy system that enables image processing on the cloud. This cloud endoscopy system utilizes Olympus technology for endoscopes to perform image processing (which has been conventionally processed within the endoscopic equipment) on a remote cloud.
According to product literature, “NTT’s IOWN APN technology makes it possible to process images in real time on the cloud. Through this demonstration experiment, the two companies aim to establish a reference model for the commercialization of the cloud endoscopy system, overcome the current limitations of processing performance of endoscopic equipment, improve maintainability, and provide a flexible and rapid market response to the market.”
It's expected that with increased future cases, the need will surge for flexible feature improvements and updates, such as real-time remote diagnosis and treatment. Therefore, according to NTT and Olympus, “There is discussion on cloud computing endoscopes, in which some functions with a high processing load, such as image processing, can be done in the cloud. By sharing the processing load with built-in data centers, users can receive the latest functions through software updates on the cloud and enable real-time remote diagnosis.”
EVIS X1 Endoscopy System
The Olympus EVIS X1 Endoscopy System introduces a range of technologies that aim to revolutionize the way physicians can detect, characterize and treat gastrointestinal disorders.
According to Olympus, the system provides a combination of diagnostic and therapeutic innovations—alongside well-established technologies—to streamline and improve endoscopic procedures and scope handling.
GI Genius
The GI Genius endoscopy module from Medtronic detects colorectal polyps through enhanced visualization during colonoscopy. According to Medtronic marketing materials, the GI Genius module has been shown to increase adenoma detection rates by up to 14.4%.
The GI Genius intelligent endoscopy module helps the physician detect colorectal polyps of various sizes, shapes, and morphologies. The module has a 99.7% sensitivity rate and less than 1% false positives, according to Medtronic.
Red Dichromatic Imaging
Gastrointestinal bleeding is a serious challenge, involving considerable mortality of 2%-10% and high management costs. Consequently, prevention of complications is crucial. According to Olympus, its RDI technology improves the visibility of bleeding points within the mucosa and enhances the visibility of deep blood vessels compared to white light.
Identification of bleeding spots through RDI technology makes hemostasis quick and easy, Olympus marketing materials state. Therefore, RDI technology may help to reduce stress and procedure time for emergency bleeding and endoscopic resection.
Single-Use Bronchoscopes
Ambu is offering a bronchoscope called the aScope 4 Broncho for airway inspection, BAL/BW and flexible bronchoscopic intubation. For more advanced critical-care procedures the aScope 5 Broncho HD is appropriate for: percutaneous tracheostomy, hemoptysis, cryotherapy, transbronchial biopsy and foreign-body removal.
Ambu is also providing new thin and ultrathin single-use bronchoscopes for “small anatomy” called the aScope
5 Broncho 4.2/2.2 and aScope 5 Broncho 2.7/1.2. The thin, single-use bronchoscope “is perfect for peripheral bronchoscopy procedures, features a regular-sized working channel, and is compatible with commonly used endotherapy instruments and active tools,” according to Ambu.
TXI Technology
Precursor lesions are often tiny and far too easy to overlook. With that in mind, TXI technology from Olympus was designed to increase the visibility of potentially suspicious lesions and polyps by enhancing image color and texture during endoscopic screening.
Olympus marketing materials state that a trial published in Gastroenterology in October 2023 “revealed TXI technology significantly improves the adenoma detection rate (ADR) by 13.61%, and the rate of adenomas per colonoscopy (APC) ≥ 5mm in size, versus white-light endoscopy (WLE), highlighting its ability to support clinicians in identifying potential precancerous lesions and enhancing the quality of their colonoscopies.
“TXI technology is designed to emphasize image information by combining the three image-processing algorithms: brightness correction of the dark part of the image; color-difference expansion processing; and texture-component emphasis processing,” the marketing materials continue. “The incoming image is split, and the texture and brightness are enhanced before the separate images are merged back together. Additional color enhancements are made to define subtle tissue differences more clearly.”
Conclusion
The endoscopy industry has always been rife with innovation and is poised for continued inventiveness, driven by the need to improve diagnostic accuracy, treatment effectiveness, and accessibility of care. These advancements are expected to lead to more minimally invasive procedures, better patient outcomes, and a wider range of applications for endoscopy in the future. For endoscopy, the sky’s the limit!

### Weight Management and Endoscopy
In this article we’ll examine the role of endoscopy in weight management and how to provide insights and strategies for working with patients on weight-related health issues. As a seasoned board-certified, family medicine physician, industry thought leader and creator of my own science-driven approach to sustainable weight management (called MELTOFF.Health), I’ve seen firsthand the importance and efficacy of minimally invasive to noninvasive practices that help aid in weight management.
Endoscopy, in regard to weight management, is minimally invasive and one the best diagnostic tools we have to get to the root cause of weight gain (or loss) from a biological standpoint. As readers of this magazine are well aware, endoscopes are used to examine internal systems, organs, obstructions and structures. Endoscopes are also a valuable tool for initial assessment and are also used in treatment procedures for overweight patients who struggle with obesity despite their best weight-loss efforts.
When used holistically with a focus on the mental health and emotional components of the individual patient in addition to the use of medical procedures, weight-loss results improve and sustained management can be achieved.
When used diagnostically, procedures such as colonoscopy or upper gastrointestinal endoscopy are often performed if there is concern that the patient’s weight loss or gain could be caused by a physical condition or disease that can be discovered, assessed and observed internally using the flexible tube, light and camera of the endoscope. This window into the human body provides tremendous insight and better diagnostic ability than ever before, resulting in a much more accurate diagnosis and treatment plan for the patient. Once the diagnosis has been made, the use of this technology continues as a means of treatment for obesity.
When used for gastric bypass or sleeve gastrectomy, an endoscopic procedure (versus an open procedure) has many benefits, the most valuable being a shortened recovery timeline and limiting hospital stays due to the lack of incision. One of the most common weight-loss procedures, endoscopic sleeve gastroplasty (or ESG), is performed less invasively through the mouth.
This treatment uses sutures to minimize the size of the stomach, resulting in a significantly quicker satiated state and decreased ability for food intake, ultimately resulting in weight loss. Unlike gastric sleeve surgery, ESG is much less invasive as it does not remove any part of the stomach.
It is important to understand that weight management, whether the underlying focus is gain or loss, is not limited to just diet, exercise or medical action. More often than not, the root of obesity can be an emotional one that is not often addressed along with lifestyle changes, pharmaceuticals or medical procedures.
Without a broader assessment that takes into consideration the patient’s mental health and lifestyle habits, the results from more extreme medical measures—however less invasive—can prove to be ineffective. Putting into practice mindful and more emotionally aware eating habits on their own can prove beneficial, and when used in combination with guided goals and a health plan from a physician, the results can be much more positive. Body positivity is top of mind currently in society and the media, but it is not so easily achieved. Emotional trauma and conditioning around a negative body image are deeply rooted and enforced by our culture and society.
It is imperative that, as medical professionals who are being sought out by our patients for support of weight management, we acknowledge, address and aid in recognizing and rehabilitating these intertwined beliefs. An endoscopic procedure is absolutely not a simple, quick fix to years of emotional neglect and a deeply ingrained, negative body image.
Though less invasive, endoscopic procedures are not at all without risk, and results will absolutely vary from person to person. Similar risks to traditional surgeries—such as infection, bleeding and a negative reaction to anesthesia—can occur.
Focusing on lifelong well-being and accountability from a holistic viewpoint is often overlooked in lieu of a physical procedure that doesn’t necessarily get to the root of the problem for the diagnosis. Understanding that the physical practices and procedures are equally important as the psychological, mental and emotional health of the patient is a proven, unparalleled approach to success.
The best weight-management program that leads to sustained weight loss is a process best undertaken alongside a medical professional’s guidance and care.

### An Alternative to Plastic
Plastics. They’re everywhere. And it’s not good.
In fact, it’s very, very bad.
These days there’s a lot of erroneous “health” information out there, and it’s hard sometimes to know what deserves alarm and what doesn’t.
Plastics deserve alarm.
Even those people who are not concerned about the environment must surely be concerned by studies that show imaging of human brains that contain as much plastic as a plastic spoon.
Fortunately, several companies are trying to address this problem. One such company is PlantSwitch. The mission of the PlantSwitch team is to replace all petroleum-based, single-use plastics with sustainable, plant-based alternatives. Using proprietary technology, the company upcycles agricultural residues into a high-performance, plant-based resin that serves as an affordable, zero-waste alternative to traditional plastic. The following is a Q&A with Dillon Baxter, co-founder and CEO of PlantSwitch.
Dillon, tell us more about this alternative to plastic.
The material is designed to seamlessly integrate into existing manufacturing processes, making it a true drop-in replacement for traditional plastic, without sacrificing quality or functionality. From cutlery and straws to plates, packaging and beyond, the company’s resin can be used to create nearly any plastic product without the environmental cost or the cost to human health.
Please explain what damage plastics are doing to the environment and health of living things on our planet.
Plastics are no longer just a waste issue, but a systemic environmental crisis. Every year, millions of tons of plastic enter our oceans, rivers, ecosystems and, recent studies show, our bodies and food sources. The impact on our ecosystems  is  profound.  Microplastics  are  ingested  by fish, birds and other wildlife, often leading to malnutrition, poisoning and death. As they move through the food chain, these pollutants accumulate and magnify, posing growing risks to biodiversity and ecological balance.
Studies are now showing that microplastics (microscopic plastic particles) are being found in our hearts, livers, kidneys and brains. They are also being found in breast milk, the placenta, and our reproductive organs.
How important is it for the healthcare industry in particular to consider alternatives to traditional plastics?
Ironically, many of the plastic materials used in healthcare that are intended to promote healing may actually be contributing to long-term health risks. Single-use plastics, particularly those containing phthalates, BPA and other additives, have been linked to hormone disruption, cancer, autoimmune diseases, and developmental disorders.
Healthcare is one of the largest worldwide producers of plastic waste. From gloves and syringes to IV bags and packaging, the sector relies heavily on single-use plastics for hygiene and convenience. However, this has created a staggering waste stream that ends up in landfills or incinerators, contributing to environmental pollution and greenhouse gas emissions.
PlantSwitch currently provides their products to Boston Medical and to Fort Healthcare, and there are more such partnerships in the works. Please tell us more about these partnerships.
We are proud to partner with providers who prioritize sustainability and innovation by choosing PlantSwitch cutlery and straws for their food-service operations. Healthcare is a key area where we see tremendous potential for growth, as replacing single-use plastics represents a meaningful step forward for patient well-being and the health of our planet. Potential uses might include syringes and IV clips, patient wristbands, etc.
What tips do you have for healthcare professionals who want to reduce plastic use in their facilities, and/or who want to find alternative products?
I commend healthcare professionals who are taking any steps toward more sustainable practices. Even incremental changes can lead to significant impact over time. For example, simply replacing 1 million plastic forks with PlantSwitch alternative plastic for their staff and patient food services can prevent nearly 9,000 pounds of plastic from entering the waste stream.
How important is it that we find immediate solutions to this problem?
Plastic production is set to triple by 2060 if current trends continue. The longer we delay action, the more entrenched the crisis becomes. Plastics are polluting and accumulating at a pace our planet cannot absorb or process. Our planet cannot afford to wait longer for solutions to plastic.
Sometimes even solutions have flaws. Are there any flaws to plant-based plastics that we should be considering (even if these products are far better than traditional plastics)?
As with the development of any new product, achieving the ideal formulation often involves a period of trial and refinement. Depending on the specific application, it can take multiple iterations to perfect the blend, consistency and thickness needed to match or outperform traditional plastic. However, our team of engineers and scientists has developed deep expertise in this area and has successfully fine-tuned the process to deliver reliable, high-performance results.
How optimistic or pessimistic are you about how humanity will face our plastic crisis?
I would describe my outlook on humanity’s response to the plastic crisis as cautiously optimistic. On one hand, the urgency has never been clearer. We are now seeing microplastics in our food, our oceans, and our bodies, and public awareness is rising. However, the plastic crisis is accelerating, and in many regions, plastic production is still growing unchecked. So yes, I believe we can solve this. But it’s going to take bold leadership, global cooperation, corporate cooperation, and relentless innovation.
One major step in this progress is PlantSwitch’s adaptability. PlantSwitch offers a drop-in solution to existing plastic thermoforming machinery and injection molding machinery, making it much more convenient and cost effective for companies to adopt on a large scale. People can learn more about our manufacturing process and the source of our compostable, bioplastic material at PlantSwitch.com.

### Financial Literacy for Nurses
For America’s 4.3 million registered nurses, financial advice that caters to traditional workers often falls short. Personal finance recommendations are typically designed for individuals with 9-to-5 jobs, stable income streams and predictable expenses. Yet the realities of nursing—a profession sometimes defined by irregular schedules and fluctuating income—require a completely different approach.
The widespread lack of financial education among nurses and the broader population compounds the issue. Bridging this gap requires understanding the profession’s unique demands and tailored financial strategies to meet these challenges.
The 12-Hour Reality Check
Mainstream financial advice often focuses on cutting costs in areas like coffee-shop runs or eating out, with suggestions like “skip the latte” or “pack your lunch.” However, such advice rarely accounts for the taxing demands of a 12-hour nursing shift, particularly in critical care or emergency units.
For nurses working through the night in high-stress environments, a $7 hospital cafeteria coffee is not a luxury, but a necessity. This “survival fuel” keeps them alert and functioning during grueling hours. Even packing meals isn’t as simple as it sounds. Refrigerators in hospital break rooms are often overcrowded, poorly maintained or outright hazardous.
These realities make generic financial tips impractical and underscore the need for advice that is appropriate for the unpredictable nature of nursing schedules and working conditions.
Irregular Income, Irregular Solutions
Budgeting on a consistent income is the cornerstone of most financial-planning advice. However, for many nurses, paychecks fluctuate from month to month due to overtime shifts, float assignments and bonuses. In 2024, base salaries for registered nurses ranged from $77,600 to $120,000 or more annually, depending on location, specialty and experience. However, this is just the starting point. Many nurses supplement their income significantly through the following:
 	Shift differentials: Night shifts often pay an additional 10% to 20% more.
 	Weekend premiums: These can add $3 to $5 per hour.
 	Critical staffing bonuses: Hospitals sometimes offer $100 to $500 per shift during staffing shortages.
 	Overtime pay: Time-and-a-half or even double-time pay for hours worked beyond the standard schedule.
 	These variable income streams, while lucrative, make traditional budgeting strategies insufficient and unsustainable. Relying on working overtime consistently can result in burnout and the likelihood of making workplace mistakes. Nurses need tools and techniques that account for irregular earnings and prioritize financial stability.
The Hidden Costs of Caring
Nurses face a range of professional expenses that are often overlooked in traditional financial planning:
 	Licensing fees: Annual renewals range from $50 to $150 depending on the state.
 	Continuing education requirements: Keeping up with certifications and licensure costs $500 to $1,000 annually.
 	Footwear: Nurses on their feet for 12-hour shifts require comfortable shoes, costing $120 to $200 per pair. Given the job’s physical demands, these shoes often need replacing every three to six months.
 	Uniforms: Scrubs and other workwear typically cost more than $500 annually (Burns, 2024).
 	Liability insurance: This critical safety net costs $100 to $500 annually.
These recurring expenses quickly add up, creating a financial strain that generic advice often fails to address.
Investment Challenges for Night Shift Nurses
One of the less obvious financial challenges nurses face is the misalignment between their schedules and the financial markets. The stock market operates during traditional business hours, making it difficult for night shift workers—approximately 30% of the nursing workforce—to manage investments actively.
Beyond timing, the larger issue lies in the lack of financial education about investing. Many nurses graduate without understanding basic concepts like compound interest, diversification or portfolio management. This knowledge gap can delay or even prevent nurses from building long-term wealth. Automated investment tools, such as robo-advisors, can help bridge this gap by providing simple, user-friendly platforms for investing without requiring constant oversight.
The Burden of Student Loans
Nurses often enter the workforce carrying significant student-loan debt. While aggressive repayment strategies are commonly advised, nurses have access to unique repayment options that require careful consideration:
 	Public service loan forgiveness (PSLF): Many nurses qualify, but the program’s requirements are complex and subject to legislative changes.
 	Health Resources & Services Administration (HRSA) Programs: These offer repayment assistance for nurses working in underserved areas.
 	State-specific forgiveness programs: Many states incentivize nurses with loan forgiveness in exchange for service in critical-need areas.
 	Employer-based loan repayment: Some hospitals and healthcare organizations provide direct loan repayment as part of their benefits package.
 	Income-driven repayment plans: These plans adjust monthly payments based on earnings, accommodating the overtime and bonuses that nurses frequently receive.
Navigating these options requires a thorough understanding of the programs’ terms and how they fit into a nurse’s broader financial goals.
Retirement Planning in Nursing
Retirement planning presents unique challenges for nurses, particularly in physically demanding specialties. A TIAA Institute study found that 33% of healthcare workers feel unprepared for retirement, and nurses are no exception.
Key factors include:
 	Earlier retirement: Many nurses aim to retire early due to their work’s physical and emotional toll. Some may choose gradual retirement by reducing their hours. This decision also impacts financial planning.
 	Workplace injuries: Nurses experience 8.8 workplace injuries per 100 full-time employees, which can disrupt retirement savings plans.
 	Decline of pension plans: While some public hospitals do still offer pensions, these benefits are becoming increasingly rare.
 	Disability insurance: Comprehensive coverage is essential for nurses, given their higher risk of injury. Approximately half of workplace injuries among nurses result from routine tasks such as lifting patients, bending or reaching. Disability insurance for nurses typically covers about 60% to 80% of their income. The cost of this insurance generally ranges from 1% to 3% of a nurse’s annual salary.
Retirement planning requires a proactive approach, including maximizing employer-matched contributions, exploring tax-advantaged accounts and considering alternative income streams.
Creating a Budget for Irregular Income
Nurses with fluctuating pay need budgeting strategies that prioritize stability and flexibility.
 	Base budget: Build a budget around base salary or guaranteed income.
 	Shift differential fund: Set aside income from overtime and bonuses into a separate account for irregular expenses or savings goals.
 	Emergency fund: Maintain six to nine months’ worth of living expenses to cover potential injuries, job changes or unexpected life events.
Investing With a Busy Schedule
For nurses balancing demanding work schedules, passive and automated investment strategies are often the best option.
 	Robo-advisors: Several platforms offer automated portfolio management tailored to individual risk tolerance.
 	Employer retirement plans: Nurses should maximize contributions to employer-sponsored 401(k) or 403(b) plans, especially if their employer offers matching contributions.
 	Target-date funds: These funds automatically adjust risk levels based on the expected retirement date, offering a hands-off approach to investing.
Tax Planning
Nurses often overlook potential tax savings, leaving money on the table. A CPA or tax professional can help navigate these challenges.
 	Deductible expenses: Track expenses like uniforms, liability insurance and continuing education for potential deductions.
 	Overtime tax implications: Be mindful of how overtime and bonuses can push you into a higher tax bracket, and plan accordingly.
 	Travel nurse taxes: If working across multiple states, plan for additional tax filings and understand state-specific obligations.
Student Loan Optimization
To manage student-loan debt effectively, nurses should:
 	Stay informed about updates to programs.
 	Leverage any available employer-based loan repayment assistance programs.
 	Regularly reassess repayment plans to align with income changes and career goals.
The Future of Financial Planning for Nurses
Nurses’ financial challenges will become even more complex as the healthcare industry evolves. The rise of travel nursing, increasing specialization and changes in compensation models require a shift away from cookie-cutter financial advice. Tailored financial planning for nurses can include:
 	Specialized advisors: Seek financial advisors who are experienced in working with healthcare professionals.
 	Nursing-specific groups: Join forums or organizations focused on financial literacy for nurses.
 	Holistic job evaluations: Consider the complete benefits package when evaluating job offers, not just the base salary.
Financial literacy is critical for nurses to build wealth and achieve financial independence. Educational initiatives, such as employer-sponsored programs, online courses or professional organizations, can equip nurses with the knowledge they need to make informed decisions.
Protect Your Financial Health
For nurses, financial health is as essential as physical and emotional well-being, yet it often receives less attention than it deserves. The demanding nature of the healthcare profession can lead to financial stress, which can in turn impact overall job performance and personal satisfaction. Addressing the unique challenges faced by nurses requires a shift toward specialized advice and proactive financial planning that considers their specific circumstances and goals.
Nurses frequently encounter a myriad of financial pressures, including student-loan debt, unpredictable work hours, and the need to plan for retirement at a time when healthcare costs are continually rising. Emphasizing the importance of tailored financial strategies is crucial for helping nurses navigate these challenges effectively. For instance, developing a clear budget that accounts for irregular income patterns can be vital in managing living expenses and savings goals.
Furthermore, understanding the various benefits available to nurses, such as loan forgiveness programs and retirement accounts tailored for healthcare professionals, can significantly enhance their financial stability. By utilizing these resources, nurses can bolster their financial wellness and set themselves up for long-term success.
Embracing proactive financial planning also allows nurses to alleviate stress and concentrate on what they do best— providing exceptional patient care. When equipped with the right tools and knowledge, nurses can make informed decisions about investments, savings and debt management. This not only enhances their financial future but also contributes to their overall well-being and professional fulfillment.
Prioritizing financial health empowers nurses to pursue their careers with confidence and peace of mind. By embracing personalized financial strategies, they can create a solid foundation for their futures, ultimately leading to improved job performance and a higher quality of life inside and outside the workplace. The journey toward financial well-being is an empowering process that fosters resilience and enables nurses to thrive in their vital roles within the healthcare system.

### Flexible Endoscope Cleaning
Ensuring the efficacy of endoscopes is paramount in preventing healthcare-associated infections. This process involves rigorous testing to verify that cleaning and disinfection protocols effectively eliminate contaminants. Key aspects of this testing include verifying cleaning procedures, detecting residual proteins or microbes and evaluating the effectiveness of drying and storage practices. Through meticulous assessment, healthcare facilities can safeguard patient health and uphold the highest standards of hygiene. Not knowing which guidelines or standards to follow can lead to inefficiencies, confusion or missed steps.
The Association for the Advancement of Medical Instrumentation 91 (AAMI ST91) is a comprehensive standard for the reprocessing of flexible and semi-rigid endoscopes in healthcare facilities. AAMI ST91 accentuates the critical importance of quality assurance and verification in the reprocessing of endoscopes. This standard requires healthcare facilities to implement strong programs that ensure the efficacy of both mechanical and manual cleaning steps. Significant components of these programs include verification tests, particularly for high-risk endoscopes, and regular monitoring of reprocessing procedures.
AAMI ST91 Compared to Other Guidelines
Let’s explore AAMI ST91 versus the Society of Gastroenterology Nurses and Associates (SGNA). AAMI ST91 provides detailed guidelines on every step of the reprocessing procedure, including precleaning, leak testing, manual cleaning, rinsing, visual inspection, high-level disinfection, drying and storage. SGNA standards also cover these steps but may not be as detailed in certain areas. ST91 emphasizes verification tests and regular monitoring of reprocessing procedures, particularly for high-risk endoscopes. SGNA standards also recommend verification but may not mandate it as strictly.
Next, let’s compare and contrast AAMI ST91 with standards from the Association of Perioperative Registered Nurses (AORN). AAMI ST91 places significant emphasis on high-risk endoscopes, such as duodenoscopes, bronchoscopes and ureteroscopes, requiring stringent cleaning and verification procedures. AORN guidelines also address high-risk endoscopes but may have different recommendations for specific procedures. AAMI ST91 recommends using lighted magnification and borescopes for visual inspection, which is a more specific requirement than AORN guidelines.
Now let’s take a look at AAMI ST91 versus the Centers for Disease Control and Prevention (CDC). AAMI ST91 and CDC guidelines stress the importance of comprehensive quality-assurance programs. However, AAMI ST91 provides more detailed instructions on the implementation and verification of these programs. AAMI ST91 mandates competency training for personnel involved in endoscope reprocessing, aligning closely with CDC guidelines that also emphasize training but may not specify the same level of detail.
AAMI ST91 is renowned for its detailed and specific guidelines, particularly in the areas of verification and monitoring processes. Its emphasis on high-risk endoscopes and the use of advanced inspection tools, such as borescopes, distinguishes it from other standards. Overall, AAMI ST91 is recognized for its thorough approach to ensuring the efficacy of endoscope reprocessing, making it a critical standard for healthcare facilities aiming to prevent healthcare-associated infections.
Visual inspection is an essential step in reprocessing flexible endoscopes, ensuring these complex instruments are thoroughly cleaned and safe for patient use. This process involves examining the endoscope and its accessories for any residual debris, damage or defects that could compromise the effectiveness of subsequent cleaning and disinfection steps. Identifying issues such as leaks or retained debris early on helps prevent cross contamination and reduces the risk of healthcare-associated infections. Additionally, visual inspections can uncover wear and tear or other damage that might necessitate repairs, thereby extending the lifespan of the endoscope and maintaining its functionality.
By incorporating routine visual inspections into the reprocessing protocol, healthcare facilities can uphold high standards of hygiene and patient safety. The use of lighted magnification and borescopes significantly enhances visual inspections, allowing for detailed examination in areas that are challenging to see with the naked eye. There are even borescopes on the market such as Watchdog AI with an artificial intelligence program to aid in the detection of defects and soil inside the endoscopes.
Various innovative products have been developed to enhance the cleaning process. For instance, the revolutionary UltraZonic ENDO semi-automated pre-cleaning machine excels in removing contaminants from flexible endoscopes. This advanced technology performs leak testing, pre-cleaning, first flush, brushing, final flushing and rinsing for multiple endoscopes simultaneously. A Belgium-based, high-tech R&D and manufacturing company specializing in infection-control technologies, UltraZonic has established a global distribution network, making its innovative solutions accessible worldwide.
Take a Little Time
A potential misstep—but an important one—is to leak test the endoscopes after each use. Leak testing flexible endoscopes identifies the endoscopes’ waterproof integrity to ensure patient safety. This process detects damage to the external surfaces and internal channels that could lead to fluid invasion during procedures. If fluids penetrate the endoscope, it can compromise the device’s functionality and lead to cross contamination, presenting significant infection risks to patients.
Furthermore, leak testing helps prevent costly repairs by identifying potential issues early, thereby extending the lifespan of the endoscope. By regularly performing leak tests, healthcare facilities can ensure that their endoscopes remain in optimal condition, safeguarding both equipment and patient health.
Another example that supports cleaning efficacy is the novel double-headed disposable brush, which has shown superior cleaning performance compared to conventional brushes, particularly in reducing bacterial presence in endoscope channels. This brush is especially important for complex endoscopes, such as duodenoscopes and bronchoscopes, which have intricate channels and lumens that are challenging to clean thoroughly. The double-headed design allows for more effective scrubbing and removal of biofilms and residual debris, ensuring that these high-risk endoscopes are properly sanitized and safe for patient use. Given the complexity of these devices, using advanced cleaning tools like the double-headed brush supports high standards of cleaning and infection prevention.
Using high-quality detergents made for cleaning endoscopes is essential in healthcare settings to ensure the thorough cleaning and disinfection of medical instruments, including flexible endoscopes. Medivators’ cleaning solutions, for example, are specifically formulated to effectively eliminate biofilms, which are often resistant to standard detergents. Biofilms can harbor harmful pathogens, making them a significant risk factor for healthcare-associated infections. High-quality detergents are designed to break down these resilient biofilms, ensuring that endoscopes are properly sanitized.
Moreover, these detergents can remove tough organic residues, such as blood and bodily fluids, which can contain infectious agents. The use of advanced cleaning solutions helps maintain the integrity of the endoscopes while ensuring they are free from contaminants. This is particularly important for complex endoscopes like duodenoscopes and bronchoscopes that are known to have cleaning challenges. By using high-quality detergents, healthcare facilities can adhere to stringent infection-control standards, minimize the risk of cross contamination, and safeguard patient health. Choosing the right detergent makes a stark difference in cleaning capability.
Once the endoscope is manually cleaned, verifying the cleanliness of the inside channel of an endoscope should be performed. Protein residue testing—via Scope-Check, ChannelCheck and EndoCheck—plays a vital role in this process by detecting residual proteins on the endoscope surface and within its channels. These tests help confirm that the cleaning procedures have effectively removed the organic matter that can harbor harmful pathogens.
Microbial testing, including microbial cultures and bioburden tests, assesses the effectiveness of disinfection and sterilization by checking for the presence of microbes after processing. These tests are excellent ways to verify that the endoscope is free from microbial contamination, ensuring it is safe for patients. Utilizing these verification tests enables healthcare facilities to ensure rigorous cleanliness standards, minimize infection risks and enhance patient safety.
Dry-testing flexible endoscopes after processing verifies that all channels are thoroughly dried, as residual moisture can create an environment conducive to microbial growth. Studies have demonstrated that methods such as alcohol flushes and hanging endoscopes in cabinets may not adequately dry channels. Even with compressed-air drying, some channels can remain moist, posing a risk of contamination. Effective drying is essential to prevent the proliferation of waterborne pathogens and environmental contaminants, which can compromise patient safety. Implementing rigorous dry-testing protocols provides an optimal way to ensure flexible endoscopes are completely dry after processing.
Adhering to best practices in endoscope cleaning efficacy is essential for ensuring patient safety and preventing healthcare-associated infections. Implementing rigorous cleaning, verification and monitoring protocols allows healthcare facilities to effectively eliminate contaminants and reduce the risk of cross contamination. Advanced tools and techniques, such as lighted magnification, borescopes and high-quality detergents, enhance the thoroughness of the cleaning process. Regular competency training for personnel and adherence to standards like AAMI ST91 help ensure that reprocessing procedures are consistently performed to the highest standards. Following these best practices is the optimal way to safeguard patient health and maintain the integrity of medical devices.

### ‘Levity Helps Keep Us Grounded’
The jokes are rolling at Carle Health Endoscopy Center, in Peoria, Illinois, but first and foremost is patient safety.
“I personally love that we have fun together at work,” said Jamie Remick, RN. “We joke with each other and patients. We know this is a serious situation, but levity helps keep us grounded. … We really are a team where all members work together. There isn’t any one person who puts their needs above anyone else’s. We know that patient care comes first, and we all do what needs to be done to get the job done right the first time.”
Those efforts must be working, as Carle Health Endoscopy Center was recently awarded the “Best Colonoscopy and Endoscopy” ranking from U.S. News & World Report’s inaugural Best Ambulatory Surgery Centers ratings.
“We were so excited to find out that all of our hard work truly does pay off,” Remick said. “This is our ‘every day,’ but we know it’s not our patients’ ‘every day’ [so] we try to make every patient feel safe. We have an uplifting environment and our patients can feel that we are here to make them feel comfortable during their exam. We are the most compassionate team there is with the best techs and nurses there are. We can get you in and out within an hour, and your care will be top-notch.”
The U.S. News & World Report ranking is validating, said Scott Wu, M.D., medical director of Carle Health Endoscopy Center, Peoria.
“We appreciate the designation as one of the nation’s best ambulatory surgery centers for endoscopy and colonoscopy screenings, particularly during a time when those procedures continue to grow in importance for identifying issues, treating patients, and helping save lives,” Wu said. “This is a validation of the hard work and quality provided by Carle Health physicians and our staff in greater Peoria.”
Factors in the ranking include how well a facility has avoided complications, emergency transfers and other poor outcomes.
The Carle Health Endoscopy Center team performs 35-45 procedures a day, including colonoscopies, upper GI endoscopies and flexible sigmoidoscopies. The facility has five pre-procedure bays, three procedure rooms and six recovery bays.
Regardless of procedure type, every patient is treated as a family member, according to Josh Roy, RN, BSN, the facility’s RN supervisor.
“Our team works together to give quality care to our patients,” Roy said. “Our team is cross-trained to perform different tasks, which allows us to adapt to different situations.”
The team consists of six doctors, three CRNAs, 22 RNs and nine technicians.
“One of the ways our team bonds is [by] having gatherings outside of work,” Roy added. “[For instance], this past year, our charge nurse had a bonfire at her home.”
Every team has its challenges, though.
“One of the challenges we are facing is the increased number of cancellations,” Roy said. “More patients are canceling the day of their procedure, or no-show. We are currently performing a quality improvement study in hopes to decrease the number of cancellations.”
As the team members try to find solutions, they’ll surely keep having fun along the way.

### Bleeding at the NIH
I’ve tried hard to keep politics out of this magazine. After all, it’s a medical magazine, not a
political forum. However, political interests keep blasting their way into the medical field, left
and right—no pun intended—to the point that it’s sometimes impossible to discuss changes
in the medical field without discussing politics. On one such matter—federal cuts to medical
research—I’m going to step into the fray.
You’ve likely heard that the current presidential administration is making major cuts to
scientific funding. According to a recent article from the Journal of the American Medical
Association, the Trump administration “has proposed to Congress a 43% cut to next year’s
NIH budget, equivalent to $20 billion per year.” Few institutions have been as vital to American
innovation and public health as the NIH, a backbone of medical breakthroughs, but the
current administration’s cuts to federal research funding have cast a long shadow over this
critical engine of innovation.
According to The New York Times, “In his first months in office, President Trump has slashed
funding for medical research, threatening a longstanding alliance between the federal government
and universities that helped make the United States the world leader in medical
science. …In all, the [NIH], the world’s premier public funder of medical research, has ended
1,389 awards and delayed sending funding to more than 1,000 additional projects. … From
the day Mr. Trump was inaugurated through April, the agency awarded $1.6 billion less
compared with the same period last year, a reduction of one-fifth.”
These cuts have created an atmosphere of uncertainty, turmoil and risk for researchers
who rely on federal funding. Worse yet, the cuts may deprive the nation of groundbreaking
discoveries. NIH funding reductions will slow progress on some of the most pressing health
challenges facing our nation: cancer, Alzheimer’s disease, genetic disorders, infectious diseases,
and more. Delays in funding can mean postponed clinical trials, hindered development
of new therapies, and the shelving of innovative ideas before they even reach the testing
phase. When scientific advances are stalled, so too are improvements in diagnosis, treatment
and prevention that could save lives and reduce healthcare costs.
A reduction in NIH grants could also weaken the United States’ leadership role as countries
around the world continue to invest heavily in their own scientific infrastructures. American
scientists may seek research opportunities elsewhere, taking vital talent and innovation
with them. The economic impact is also troubling, since healthcare innovation fueled by
NIH-supported research often translates into new jobs and economic growth. Underfunding
can slow the commercialization of new treatments and diminish the development of startups.
Investment in the NIH is essential—not just for scientists and clinicians, but the very health of
our society. It should be our collective responsibility to ensure that scientific research remains
a cornerstone of national policy, regardless of political views. If not, crucial consequences will
continue to reverberate across the scientific community and beyond. I will now, happily and
with great relief, step back out of the fray.

### FDA Blocks Imports of Certain Olympus Medical Devices from Japan
Date: June 24, 2025
The U.S. Food and Drug Administration (FDA) has issued an import alert on select medical devices manufactured by Olympus Medical Systems Corporation in Japan. This action comes after repeated Quality System Regulation (QSR) violations at Olympus’ Aizu manufacturing site. As a result, affected devices will be detained and refused entry into the U.S.
Devices Affected by the Import Alert
The import alert applies to specific models of:
 	Ureterorenoscopes – used for urinary tract procedures
 	Bronchoscopes – used for diagnostic procedures in the lungs
 	Laparoscopes – used in abdominal and pelvic surgeries
 	Automated Endoscope Reprocessors (AERs) – used to disinfect reusable scopes
Note: The alert does not apply to replacement parts, connectors, or single-use consumables.
What Health Care Providers Should Do
 	Review your inventory: Use FDA’s AccessGUDID database to confirm if your device is affected.
 	Continue safe use: If devices are working properly, they may be used. Do not cancel or delay procedures without patient discussion.
 	Follow cleaning and reprocessing guidelines: Use Olympus’ official instructions. Do not use damaged or leaking devices.
 	Schedule routine maintenance: Perform regular inspections as recommended by Olympus.
 	Report adverse events: Use FDA MedWatch or follow your facility’s MDR procedures.
Why the FDA Took This Action
Despite ongoing dialogue, Olympus failed to resolve key compliance issues at its Aizu site. This includes violations of:
 	Quality System Regulation (QSR)
 	Current Good Manufacturing Practice (CGMP)
 	Medical Device Reporting (MDR) requirements
Import Alert 89-04 allows the FDA to stop shipments of noncompliant medical devices before they reach U.S. healthcare providers.
Understanding Unique Device Identifiers (UDI)
Each affected device has a Unique Device Identifier (UDI) printed on the label or packaging. You can use the UDI or Device Identifier (DI) to search the AccessGUDID database and confirm if your device is part of the alert.
Report Problems to the FDA
If your facility experiences issues with any Olympus devices, take these steps:
 	Submit a report through MedWatch
 	Follow your facility’s MDR procedures if reporting is required
Reporting helps the FDA identify and respond to potential device safety risks quickly.
Contact FDA for More Information
For questions or clarification, contact the FDA’s Division of Industry and Consumer Education (DICE):
 	Email: DICE@fda.hhs.gov
 	Phone: 1-800-638-2041
Stay informed: The FDA will provide updates as more information becomes available.

### Remembering Mick Reed (1945–2025)
Dwight “Mick” Reed, beloved husband, father, grandfather, and founder of a national surgical repair company, passed away on Friday, June 20, 2025, at his home in Indian Lake, Ohio, surrounded by his loving family. He was 79.
Born on November 14, 1945, in Augusta, Georgia, Mick was the son of Dwight H. Reed and Elizabeth Dent Reed. He spent his early childhood in Claypool and Warsaw, Indiana, before moving to Bellefontaine, Ohio, during his high school years. A graduate of Bellefontaine High School in 1964, Mick played varsity basketball and worked at Super Value Grocery during his teen years.
In 1965, Mick proudly enlisted in the United States Army. He was selected for the elite 5th Special Forces Group (Green Berets) and served as a First Lieutenant during the Vietnam War, where he trained the Montagnard people in tactical defense and self-sufficiency.
After returning home, Mick married Jane Cooper in 1970 in Ada, Ohio. The couple recently celebrated 55 years of marriage. Mick earned his degree from Bowling Green State University and began his career in medical sales with DePuy Orthopedics. He later expanded into surgical instrument maintenance and repair—founding Mobile Instrument Service & Repair in 1982, one of the first mobile surgical instrument repair services in the U.S. Under his leadership as CEO, the company grew to more than 400 employees and served hospitals across 49 states. The company was acquired by Agiliti Health in 2020.
Mick Reed was passionate about mentoring, job creation, and building lifelong relationships with his colleagues and employees. He took great pride in fostering a culture of opportunity and growth.
Beyond his business achievements, Mick was an avid conservationist and active member of Indian Lake Fish and Game. He enjoyed racquetball, vegetable gardening, and fishing on Lake Erie and in the Florida Keys. In later years, he cherished time aboard antique boats and visiting his lake home in Georgia. Most of all, he found deep joy in being “Papa” to his granddaughters—fishing, laughing, and bonding through their shared interests.
Mick is survived by his devoted wife, Jane; daughter Angelique (David) Anbari of Atlanta, Georgia; son Ryan (Carly) Reed of Lexington, Kentucky; and three beloved granddaughters: Leona, Minnie, and Julia. He also leaves behind his brothers Jerry and Charlie, sister Anne, extended family, and many cherished nieces, nephews, and friends.
Honoring Mick’s Legacy
In lieu of flowers, the family invites memorial contributions to two of Mick’s favorite organizations:
Tunnel to Towers Foundation – https://t2t.org/donate
2361 Hylan Boulevard, Staten Island, NY 10306
Holland Theatre – P.O. Box 524, 127 E. Columbus Ave, Bellefontaine, OH 43311
Celebration of Life
A celebration of life for Mick Reed will be held on August 9, 2025. To receive details or be added to the guest list, please email mickreedmemorial@gmail.com.

### Digestive Health Institute Uses New Screening Tool
NEWPORT BEACH, Calif.— Hoag Digestive Health Institute has become the first hospital facility in the United States to offer an esophageal cancer screening that is comprehensive, requires no sedation and that can be administered in a few minutes. The EsoGuard esophageal DNA test by Lucid Diagnostics uses advanced DNA sequencing to detect precancerous changes in esophageal cells, enabling physicians to screen patients at high risk for Barrett’s esophagus (BE) and esophageal adenocarcinoma (EAC).
EsoGuard is an esophageal DNA test which detects molecular-level changes to the esophagus in a simple swallowing procedure. Patients simply swallow a tethered capsule—about the size of a gelcap—which collects cells from the esophagus as it is retrieved. These cells are then analyzed at Lucid Diagnostics’ laboratory to determine, whether there is need for additional testing or if the patient's esophagus is healthy.
This non-invasive screening method is safe, effective, will increase screening and will lower cancer rates for people who are at increased risk of developing esophageal cancer, said Kenneth  Chang, M.D., the executive medical director endowed-chair in GI Cancer at Hoag Digestive Health Institute.
“This is a game changer in our mission towards achieving an esophageal cancer-free Orange County,” said Dr. Chang. “The incidence of esophageal cancer has increased ten-fold in the past four decades, yet most patients at risk aren’t being sufficiently screened. Adding EsoGuard to our comprehensive esophageal cancer screening program here in Orange County is a critical step forward in making diagnostics more accessible to support early intervention and ultimately save lives.”
The screening tool is recommended for those with chronic GERD, obesity, a history of smoking, or a family history of esophageal cancer or Barrett’s esophagus, a condition in which the lining of the esophagus changes. White males over the age of 50 are considered at highest risk. Detecting Barrett’s esophagus is critical, as it is the only known precursor to esophageal adenocarcinoma and studies show that treating BE can reduce cancer risk by up to 90%.
“Esophageal cancer is the 2nd most lethal cancer by survival rate in the U.S. When it comes to cancer, we know that early detection is key,” Dr. Chang said. “This tool now makes it easier for physicians to detect precancerous changes with unmatched accuracy and to quickly intervene and provide treatment to prevent the progression of the disease.”
Hoag will offer EsoGuard at the Irvine and Newport Beach Digestive Health clinics. Hoag is a nonprofit, regional healthcare delivery system in Orange County, California.
 
 

### Malaysian Endoscopy Team Completes 50 POEM Cases
KUALA LUMPUR, Malaysia—Pantai Hospital Kuala Lumpur announced in June that its staff members have successfully performed 50 peroral endoscopic myotomy (POEM) procedures since the service was introduced in 2020.
POEM is a cutting-edge, incisionless procedure used to treat achalasia, a rare disorder that affects the ability of the esophagus to move food into the stomach. The POEM procedures are led by Dr. Lau Peng Choong, a consultant upper gastrointestinal surgeon at the hospital.
"We're proud to reach this milestone of 50 POEM cases," said Dr. Lau. "This treatment has significantly improved the quality of life for patients with achalasia—a condition that's often misdiagnosed as acid reflux or anxiety. With POEM, we can now offer an effective, minimally invasive solution with quicker recovery and less discomfort."
Unlike traditional or even laparoscopic surgeries, POEM is performed entirely using an endoscope passed through the mouth. The technique involves cutting the muscles at the lower end of the esophagus to allow smoother passage of food, offering faster recovery times, less pain, and lower complication risks.

### Probiotic Breakthrough Tackles Lactose Digestion Issues
Makers of the product Bactose are calling attention to a health issue that affects millions—especially in communities of color: lactose intolerance.
Lactose intolerance affects over 36 million people in the United States, with the highest rates found in Black, Asian, Latino, and Indigenous populations. For decades, the standard advice has been to avoid dairy, rely on inconvenient fixes like lactase enzyme tablets or to substitute dairy with highly possessed dairy alternatives. Bactose offers something different: a long-term, gut-based solution that helps people digest real dairy again, in just seven days.
"We created Bactose because we knew people deserved better than just avoiding foods they love," said Brandon Tendler, co-founder and CEO. "This isn't about managing symptoms. It's about restoring balance and freedom, especially for the communities that have been living around this problem, not through it."
This avoidance creates a significant nutritional gap with far-reaching health consequences. Communities of color, who experience lactose intolerance at rates up to 90%, consistently fall short of USDA recommendations for calcium, vitamin D, and potassium—nutrients critical for cardiovascular health, blood pressure regulation, and reduced risk of type 2 diabetes.
Research shows African Americans consume only 83% of recommended calcium and just 27% of recommended vitamin D, contributing to disproportionately higher rates of certain diseases. When dairy becomes off-limits, the resulting deficiencies don't just weaken bones-they fuel the very chronic diseases that already disproportionately impact communities of color.
Bactose is the first probiotic of its kind designed to support the gut's ability to break down lactose by introducing a specific strain of bacteria that naturally aids in the digestion of lactose directly in the gut. Users take it only twice daily for seven days, the beneficial bacteria will continue producing lactase for up to a month, allowing consumers to enjoy dairy without taking pills before every meal.
For people who have cut out dairy due to discomfort, Bactose can be a life-changer. Foods like cheese, yogurt, and milk offer key nutrients like calcium, vitamin D, and high-quality protein. Bactose is helping restore access to those foods.
"We hear from people who haven't had a slice of pizza or a scoop of ice cream in years," said Tendler. "Unlike common probiotics that can take months to show results, this specialized probiotic which was specifically created to aid in the digestion of lactose, helps them enjoy dairy foods again in just one week, which has been unheard of until now."
 

### Study: Genetic Test Underused in Cancer Care
An emerging oncology tool known as broad genomic profiling or BGP is increasingly being used to help identify targeted therapies for patients diagnosed with cancer.
Rather than analyzing one gene at a time for mutations that could be related to a patient’s cancer, BGP examines multiple genes in a tumor sample all at once. This comprehensive analysis helps health care providers better understand a tumor’s entire genetic makeup so they can prescribe targeted therapies to attack the disease.
Yet despite BGP’s potential medical benefits, a new study by researchers at the Yale School of Public Health (YSPH) finds that the BGP remains widely underused—even among certain cancers for which the test is explicitly recommended.
“The adoption of BGP has been growing, but many patients are still not necessarily undergoing testing,” said Dr. Michaela Dinan, PhD, the study’s senior author and an associate professor of chronic disease epidemiology at YSPH. Dinan is also co-leader of Yale’s Cancer Prevention and Control Research Program at Yale Cancer Center.
The researchers also found that whether patients are offered the test correlates in part with sex, age, and where they live.
“The biggest take-home point for oncologists to consider is whether BGP may be helpful for their particular patient,” Dinan said.
Using information from a large Blue Cross Blue Shield health insurance claims database, Dinan and her co-authors applied a novel algorithm to examine BGP use in over 50,000 U.S. patients diagnosed with the 10 most common metastatic cancers between 2020 and 2022. The authors documented BGP use within six months of advanced or metastatic cancer diagnosis.
Throughout the study period, about one in five patients received BGP. Its use grew more common as the years progressed, rising from 15.1% of patients early in 2020 to 24.3% by mid-2022.
Despite this growth, the researchers found that the BGP test was underused in all cancers, with well under half of the patients tested in most cancer categories. This pattern held even for patients with lung, pancreatic, melanoma, and breast cancers, for which BGP is explicitly recommended under National Comprehensive Cancer Network (NCCN) guidelines. Lung cancer saw the highest use of BGP at 49%. BGP tests were used more often for suspected kidney cancer—for which BGP is not routinely recommended—than breast cancer, the study revealed.
“In lung cancer, we've gotten to the point where it should be the standard of care across the board,” said Dr. Xiao Wang, the study’s lead author and a clinical fellow in the medical oncology and hematology unit in the Department of Internal Medicine at Yale School of Medicine (YSM). The finding of 49% is “lower than we would expect,” he said.
Potential reasons for the testing disparities varied, according to the authors. Older age, frailty, female gender identity, and living anywhere but the Northeast were all associated with a lower likelihood of broad genomic profiling.
“Most diagnostic tools and treatments are often somewhat less likely to be used in older patients, since some older patients may have competing health issues or other reasons to pursue treatment less aggressively,” Dinan said. “The association with female sex was not expected and is something we hope to look into more in the future.”
By detecting gene alterations relevant to a patient’s cancer, BGP may point the way to clinical trials or to tailored treatments that depend on the mutated gene rather than the cancer type. The test may also tip physicians off to a more aggressive cancer.
Routine use of BGP has been recommended for over a decade for patients with lung cancer, for which there are nearly a dozen treatment therapies targeting different gene alterations. For patients with breast cancer, BGP tends to be more influential for second-line treatment decisions, the authors said.
In the past, Wang said, “we might test for genomic alterations individually. But as we've accumulated more and more [knowledge], we've used these broad genomic profiling platforms to test for dozens or even hundreds of genes or alterations simultaneously.”
Though it’s more comprehensive than single-gene tests, BGP is potentially slower and more expensive.
The study has some limitations. The authors note that it was conducted only among privately insured patients; the results might differ in other populations.
Wang cautioned against concluding that patients without a documented BGP received substandard care. The authors focused on BGP testing shortly after diagnosis; some patients may have gotten the test later on.
“If a patient is not going to benefit from getting the test, if it's going to take three weeks to get the test, and single gene testing can come back within a couple of days, I definitely can understand why an oncologist might forgo this type of testing,” Wang said. “That just speaks to the fact that we need to improve access for those patients and make it feasible and effective for those patients to get BGP as well.”
The study is the first in a forthcoming series of Yale-led studies that will examine the use of BGP in U.S. cancer care. Future studies will address its effects on treatments and outcomes and whether it is cost-effective.
“You can imagine that over time, as tests get faster and cheaper and we develop more and more treatments with more and more targets, that [BGP] might be more beneficial,” Wang said. “It's a really powerful tool, and we want to understand how we can best use it for our patients.”
The study appears in JAMA Oncology. Funding was provided by the National Institutes of Health.

### Singing Out of Tune
Every time I hear the term “candida,” I flash back to the 1970s, hearing Tony Orlando and Dawn singing. But I doubt it was an ode to these invasive yeasts.
The genus candida are regular denizens of our microbiome, operating in a happy symbiosis with us and our other gut bugs. Any fungal overgrowth is generally held in check by our immunological response. But as with all things in our digestive tract, it doesn’t take much to get the community balance out of whack; if we experience a change in diet, an uptick in stress, a new medical condition, or our immune system goes sideways for any one of a host of reasons, then our healthy bacteria’s numbers can take a precipitous slide. Candida takes advantage of this loss with all the enthusiasm of a four-year-old offered unlimited chocolate cake, proliferating like rabbits on Viagra.
S. A. Syed wrote how “alterations in gut flora and gene regulation raise the risk of opportunistic fungal infections in cases of immune system weakness or following antibiotic usage. Due to its ability to stick to tissues and create enzymes that dissolve barriers, candida thrives. Low immunity, improper use of antibiotics, chemotherapy, and endocrine or  nutritional  problems  are some  of  the  contributing causes to candida’s growth.”
Although  Candida  albicans gets all the press, Chung and associates wrote in the journal
Oncotarget that at least 15 others also colonize our bodies. According to Syed, “the five most prevalent pathogens— Candida albicans, Candida glabrata, Candida tropicalis, Candida parapsilosis, and Candida krusei—account for more than 90% of invasive diseases.”
It’s candida’s adaptability to its host that allows it to catch fire with immunocompromised patients, and it’s not picky about its incubator. Chung and associates wrote, “CI frequently involves the mouth, vagina, glans penis, esophagus, liver, gastrointestinal tract, respiratory tract, and skin.”
In the vagina, candida causes vaginal candidiasis; in the mouth, it’s known as thrush. The overgrowth can appear in the bowel movements of sufferers as white, yellow or brown mucus; a white, yellow or brown string-like substance; froth or foam; or diarrhea. Candida granuloma—severe and chronic— can appear on the skin, scalp, mouth or fingernails, while cutaneous candidiasis manifests as an itchy, raised red patch of pustules on folds of skin under the arms and breasts or in the groin area. Symptoms can also include white patches in the mouth, swelling, a burning sensation and cottage cheese– like vaginal discharge.
When candidiasis is at its worst, it becomes systemic: Invasive candidiasis is a serious infection of the blood or on the membranes that line the heart or brain, affecting some 25,000 U.S. patients per year.
And everyone’s a candidate. No one is immune to the possibility of overgrowth, but some folks make better hosts: pregnant people (thanks to the fluctuating hormones), diabetics, babies, hospitalized patients, and those with dentures and catheters are all at higher risk of candidiasis. In a patient with immune deficiency, candida can bloom like a wildfire out of control.
For most of us, an overgrowth of candida is mostly annoying, causing itching and discomfort. Systemic symptoms can include headache, fatigue, stomachache, flatulence, itchy skin and craving for sweets. If a patient who is receiving treatment for candidiasis develops a fever and chills, they should immediately call a doctor.
No one should shrug off these symptoms; untreated, candida can turn invasive and can even cause precancerous conditions that slide into cancer. Chung and associates wrote, “CI is not an infrequent complication of cancer and cancer-related therapy, and it may also play an active role in cancer development. The relationship between microbial infection and cancer is of great concern.”
They  argued  that  “several plausible mechanisms” support this  premise.  “First, Candida can produce compounds such as nitrosamines, which are identified carcinogens that play a role in oral cancer initiation,” they wrote. “Second, a previous study suggested that C. albicans promotes cancer through a proinflammatory response, mediated by an increase in cytokine production and adhesion-molecule expression. It is increasingly clear that the tumor microenvironment, which is largely orchestrated by inflammatory cells, is an indispensable participant in the neoplastic process. Other hypotheses, such as the induction of Th17 response and molecular mimicry, have also been proposed to explain the mechanism by which C. albicans might promote cancer progression.”
The First Date
For many women, our first experience with candidiasis showed up when we started taking oral contraceptives. For others, symptoms developed as side effects of various other medications: antibiotics, steroids, proton pump inhibitors, or medicines that cause dry mouth or “turn off” healthy bacteria. Additional triggers include a diet high in refined carbohydrates and sugar; uncontrolled diabetes, HIV, smoking, cancer, or anything that compromises the immune system; hormonal changes; and stress.
Candida isn’t contagious, exactly, but it can be spread by physical contact. Breastfeeding mothers can pick it up from babies who have thrush, and spouses can transfer it back and forth through sexual contact, including via oral sex. The disease seems to have no affiliation for gender or age; while the average age of infected patients is 57.4 years, other factors can influence its proliferation.
Practitioners diagnose candidiasis via tests and examination, including a physical exam and culture test. Average folks can chase off an outbreak with over-the-counter meds and a little time. Other at-home remedies include keeping the skin dry; limiti ng the use of anti bioti cs and hormone-disrupti ng birth-control methods; limiti ng sugary foods and keeping blood sugar in check; quitti ng smoking; and avoiding stress and heavy alcohol consumpti on. Oft en, this is enough to keep the proliferati on in check.
But for those with a compromised immune system, candidiasis is a whole other story.
Open Up Wide
The innate immune barrier in the esophagus is where the defense against candida begins, with the nonkeratinized strati fi ed squamous epithelium. If a pati ent has a candida overgrowth in the esophagus, it will show up as yellow-white patches, or plaques that cannot be removed, oft en in combination with oral thrush. Although herpes simplex virus and cytomegalovirus are among the other nasties that can cause infectious esophagitis, the most common type is esophageal candidiasis. While the oropharynx has the dubious distinction of being the most susceptible part of the GI tract to candida infection, the esophagus is second in line. And plaques can be found throughout the esophagus, or localized in the upper, middle, or distal areas.
Symptoms can include pain or difficulty swallowing, nausea, pain in the sternum area, heartburn, vomiting, weight loss, diarrhea, and melena, depending on the extent of esophageal damage. Abdimajid Ahmed Mohamed and associates wrote in the Canadian Journal of Gastroenterology and Hepatology that diagnosis may indicate
“(1) acute infection: extremely weak immunosuppression patients often die of acute fungal infection; (2) subacute infection: subacute infection may result in esophageal stricture or pseudodiverticulum; (3) chronic infection: usually from childhood, chronic infection is often associated with submucosal fungal infection and immunodeficiency.”
After confirming candida via endoscopic examination and subsequent biopsy, practitioners can contain the overgrowth with systemic oral antifungal drugs. However, “It is important to differentiate esophageal candidiasis from other forms of infectious esophagitis such as cytomegalovirus, herpes simplex virus, gastroesophageal reflux disease, medication-induced esophagitis, radiation-induced esophageal injury, and inflammatory conditions such as eosinophilic esophagitis,” Mohamed wrote. Complications can include necrotizing esophageal candidiasis, fistula and sepsis.
Further along in the gut, candida can cause gas, abdominal pain, diarrhea, nausea, bloating and cramps, among other symptoms. Patients who have some manner of compromise in the digestive tract—for example, Crohn’s disease, ulcerative colitis, gastric ulcers, duodenal ulcers and perforated ulcers—are more likely to present with candidiasis.
Syed wrote, “The three main risk factors for GI candidiasis are radiation, intestinal inflammation, and recurrent GI surgery.” But anything that compromises the immune system, including leukemia and lymphoma, or the use of cytotoxic drugs, corticosteroids or antibiotics, can cause a flare.
And candida’s toxic effects are increasing morbidity and mortality worldwide. According to Zhe Feng and associates in Frontiers in Cellular and Infection Microbiology, “When the human immune system is compromised, C. albicans can rapidly transition from nonpathogenic to pathogenic fungi, resulting in superficial or deep candidiasis, including thrush and candidemia.” Severe candidiasis kills approximately a million people worldwide every year—no small source of concern to healthcare practitioners.
Testing, 1, 2, 3
Diagnosing an overgrowth can be tricky; histological evidence can’t be determined from sputum or stool specimens, simply because candida is a normal part of the GI tract’s normal flora. An endoscopic biopsy sample “may exhibit pathological characteristics, including multiple abscesses and an acute inflammatory response. Pseudohyphae and fungal spores are typically observed, with neutrophils predominating,” Syed wrote.
Generally, a combination of clinical symptoms and notable growth is enough for a diagnosis. And if therapy helps, you know you’re on the right track. “The alleviation of dysphagia and substernal pain that occurs after systemic anticandidal therapy is indicative of candidal esophagitis,” Syed wrote. “Because dysphagic individuals run the danger of developing strictures, esophagoscopy is advised.”
Clinicians have three popular weapons in their arsenal against candidiasis: the small-molecule antifungal medications polyenes, azoles and echinocandins. However, each has limitations.
While polyenes like amphotericin B and nystatin have been around since the 1950s, they “can induce significant adverse effects as a result of the structural resemblance between the intended target, ergosterol, and cholesterol, a sterol found in mammalian cell membranes,” Zhe Feng and associates wrote. However, as Darius Armstrong-James wrote in Parasite Immunology, “antifungal resistance to this class of drugs has not significantly emerged during this time, although there are some fungal species with intrinsic resistance, such as Aspergillus terreus and Candida lusitaneae.”
Echinocandins (caspofungin, anidulafungin and micafungin) boast a commendable safety profile and are efficient fungicides, but cost, IV administration and narrow antifungal range inhibit their practical use. Armstrong James wrote, “They target beta-1,3-D glucan synthase, inhibiting the production of beta-1,3-D glucan, an essential fungal cell wall component.”
Azoles, with their low toxicity and broad antifungal efficacy, are a popular choice. They “have the advantage of a better toxicity profile and, importantly, are available orally. Fluconazole has specific utility for Candida albicans and Cryptococcus neoformans but no activity for Aspergillus species and patchy utility across dermatophytes and endemic mycoses,” Armstrong-Hames wrote.
In addition, according to Feng, “their fungistatic effects in certain species have led to the emergence of azole-resistant isolates.” Also, the effectiveness of these treatments decreases in patients who are immunocompromised.
Other options include terbinafine, “an ergosterol inhibitor with good oral bioavailability and activity against dermatophytes and dematiaceous (black) moulds,” Armstrong-Hames wrote, and flucytosine, a flurouracil pro-drug that suffered a rapidly emerging resistance that has limited it to adjunctive use.
A recent study in the journal Microbiology Research investigated the antifungal efficacy of vitamin D₃ (VD₃) against candida. The authors, Junwen Lei and associates, concluded that VD₃ may have “multitarget effects,” reducing the fungal burden in the liver, kidneys and small intestine. They wrote, “these findings suggest a new antifungal mechanism for VD₃ and indicate that VD₃ could be an effective therapeutic agent for use in [intra-abdominal candidiasis] treatment.”
While other antifungals are in the research pipeline, there’s just no magic bullet. And the need to find one is growing.
A New Attitude
One possible therapy addresses the patient’s immune system itself. Generally, the immune system will target the fungal invader, producing inflammatory factors and activating phagocytes to attack the infection. Feng, et al., wrote, “[In] addition to playing a crucial role in initiating early defense against fungal infections, the innate immune system also triggers various responses promoted by the adaptive immune system through [dendritic cells].” Two types of adaptive immunity—cell-mediated immunity and humoral immunity— combine to build a powerful immune defense against candida... when the immune system is working properly.
When it isn’t, Feng wrote, “immunotherapeutic approaches exhibit potential as a novel strategy for treating candidiasis, owing to the significant involvement of the human immune system in managing this condition. Immunotherapies encompass therapeutic approaches aimed at targeting and impacting the immune system of the body, thereby enhancing the host’s ability to combat infections (Qadri et al., 2023). These methodologies encompass various strategies, such as augmenting the population of phagocytes, activating innate defense pathways in phagocytes and DCs, and stimulating antigen-specific immunity through means like vaccines and monoclonal antibodies.”
Antibody-based medications, Feng wrote, have exhibited positive outcomes; compared to small molecule drugs, antifungal antibodies “present a diminished occurrence of adverse reactions and a broader array of choices.” And combining antifungal medications with monoclonal antibodies provides a one-two punch against the drug resistance seen in candida.
This also “enhances specificity,” potentially becoming an asset to better patient outcomes. Novel immunomodulatory techniques integrating the regulation of recombinant cytokines with monoclonal antibodies may enhance those antibodies’ therapeutic efficacy, according to Feng. “Moreover,” they write, “emerging technologies offer promising avenues for the treatment of life-threatening invasive fungal infections.”
This immunotherapeutic approach must always take into account the immunocompromised condition of the patient, as it’s necessary to customize the therapeutic intervention. Candida-generated proteins can be effectively targeted by antibody-based medications; a side benefit is fewer adverse reactions and a “broader array” of choices, according to Feng. When combined with antifungal medications, the monoclonal antibodies can help combat rising drug resistance in candida. And because the monoclonal antibodies are patient-specific, they hold the potential for improved clinical outcomes.

### No Excuses
As a nurse and patient advocate, I feel very uncomfortable when I visit a facility and discover their practices do not meet the current guidelines or national standards for endoscope processing. Today, there are so many opportunities to easily get up-to-date information, so why isn’t everyone in our field getting that information?
For many years in my profession I have been told, “If we have been doing it this way all this time and we have no infections, why change?” I’ve also been told, “I’m too busy.”
We all know that the past five years have been challenging, with COVID-19 and the aftermath, and all the mental and economic challenges that come with constant changes to healthcare. Many of us are still struggling and have excuses, but are any of the excuses acceptable? Whose responsibility it is to ensure current information and standards are readily available so that devices can be correctly processed? Who is ensuring there is adequate staffing to comply with the manufacturer’s instructions for use for processing endoscopes?
How often do we hear about a facility breach in protocol that required letters to be sent to patients? The patients usually need to have bloodwork to see if an exposure occurred. Sometimes the alert comes from the Food and Drug Administration—or from the manufacturer itself—regarding a problem identified with a product or device. Who is designated at your facility to receive such alerts and ensure the information is given to management for follow-up?
As professionals, we all fear the word “litigation.” To avoid litigation, healthcare providers must comply with established
standards of care. Standards of care arise from regulations based on state and federal legislation or statutes. Regardless of the term used, they are the law. So to keep our endoscopes patient-ready and safe, it’s our duty to keep abreast of the most current information.
Practice guidelines, such as from AAMI, CDC, AORN and SGNA, are all applicable. Guidelines are developed by professional organizations and their members with expertise. Input can be solicited from the members before the guideline is published. However, when AAMI publishes a national standard (represented as ANSI/AAMI National Standard) it is a very different process.
“Standards are consensus documents that provide requirements,  specifications,  guidelines  or  characteristics that can be used consistently to ensure that materials, products, processes and services are fit for their purpose. AAMI develops standards documents aimed at enhancing the safety, efficacy, safe use and management of medical devices and health technologies. A standard may recommend to a manufacturer the information that should be included with a product, basic safety and performance criteria, and conformance measures that can be used to assess compliance. The inclusion of design specifications in a standard is permitted when circumstances warrant, but design specifications usually are avoided as they can hinder the advancement of technology. A standard may provide clinical users with guidelines for the use, care, evaluation or processing of medical devices.” ~ AAMI standards webpage
All AAMI documents are peer-reviewed by committee members and then sent out for public comments. AAMI committee members include product users as well as manufacturers. Once a document is completed it must be approved by a majority of the voting committee members. After approval, the document goes to the AAMI board for review and approval. If the document is to be a national standard, then the AAMI board refers the document to the American National Standards Institute (ANSI) for designation as a national standard.
When surveyors visit facilities, they will sometimes ask on what references the facility bases its processes. Some facilities use a combination of AAMI and a professional organization’s guidelines (e.g., SGNA or AORN).
In 2015, AAMI published ANSI/AAMI ST-91, “Flexible and Semi-Rigid Endoscope Processing in Healthcare Facilities.” This should be the bible for endoscope processing activities. Guidelines from other organizations are also applicable if the material is not covered in ST-91. A revised and updated version of ST-91 was published in 2021.
Practice guidelines and facility policies/ procedures are often introduced as standards of care by a prosecuting attorney trying to prove that negligence has  occurred,  meaning you  either complied with them or did not. On the other hand, a defense attorney can use the same guidelines and policies/ procedures as evidence that standards of care were met. Therefore, having policies and procedures to direct safe practice is critical to patient safety. To do this, you should reference your processing policies to the standards and guidelines used.
To  comply with  standards  and  guidelines  also  means compliance with all device processing equipment (e.g., AER) and chemical manufacturers’ instructions for use (IFU). Do you have the staffing, recommended cleaning implements,  testing  equipment,  chemicals,  processing equipment, etc., to ensure a device is safe when used on the patient?
Keeping informed is vital. Keeping processing staff updated on all matters pertaining to endoscope processing is the primary responsibility of the department or nurse manager. There are several ways to keep staff updated.
Join the Professional Association for Your Practice Area
The Society for Gastroenterology Nurses & Associates (SGNA), for instance, is a vital resource. All professional organizations have annual meetings as well as local (state) meetings that include educational programs. Seminars are also a good way to meet new colleagues. In addition, seminars often have vendor exhibits where you can see new products that can improve your practices. Join the AAMI, or at least purchase their national standard, ANSI/AAMI ST-91, to use as the baseline for endoscope processing practices.
The Joint Commission, the nation’s oldest and largest standards-setting and accrediting body in healthcare, was established in 1951 as an independent, not-for-profit organization. Its 21-member Board of Commissioners includes physicians, administrators, nurses, employers, quality experts, a consumer advocate and educators. Its offerings include accreditations and certifications, and it influences public policy through its advocacy office in Washington,
D.C. The Joint Commission expects facilities to reference its policies or specific national standards or guidelines used for its policies.
Most professional organizations have online help for questions and access to their guidelines. These same organizations offer memberships that often include regular meetings to provide education and updates on products and endoscopic procedures. Their guidelines may be offered at no cost to their members. Their websites usually have a list of all their member resources.
Sign Up for FDA Alerts
On  the  FDA  webpage,  you  can subscribe to the Center for Devices and Radiological Health (CDRH) mailing list based on your area of specialty. This will potentially alert you via email regarding pertinent information about medical device issues. While the CDRH was hit with layoffs in April of this year, the organization has not shut down. You can find them here: https://www.fda.gov/about-fda/fda-organization/center-devices-and-radiological-health
Attend Seminars and Webinars
Since the COVID-19 pandemic, with social distancing recommended and restrictions being placed on travel, virtually all organizations have relied on virtual education. Since then, it has become the norm for most of us, and today, it’s easier than ever.
Many companies that produce products used in endoscopy offer free educational programs. Contact these companies to sign up for alerts when they offer a program. Most of these programs offer continuing education credits as well. Some companies record their educational programs so you can still partake in the education on-demand when you are available. Many of these programs directly relate to endoscope processing.
Subscribe to Practice-Related Magazines
Practice-related  magazines  offer  new  information  and educational articles. For example, EndoPro Magazine and Healthcare Purchasing News, to name two. These magazines also have vendor ads where you can learn about new products or services. Make these magazines available to staff.
Documentation
Documentation is important because records can be subpoenaed in a court of law and can be used in court proceedings. Documents may also verify that staff members were properly trained. One of the most important pieces of documentation is employee training records for endoscope processing. The documentation should include details on the training used for all processing equipment, including automated dosing units (to dispense detergents), automated flushing devices, leak testers, automated endoscope reprocessors, equipment to test the accuracy of the leak tester, cleaning effectiveness testing products, and so on.
Documentation should include at a minimum the following information:
 	training instructors
 	annual competency assessments for all aspects of endoscope processing
 	dates of training and tasks/practices covered
 	the requirement to comply with manufacturer’s IFU for all equipment and products used
 	donning and doffing PPE needed for processing endoscopes
 	training provided on all makes and models of endoscopes
 	transport of used endoscopes
 	leak-testing procedures and verifying the accuracy of the leak tester
 	manual-cleaning protocols
 	inspection of endoscopes for all phases of endoscope processing
 	borescope use (if applicable) to inspect channels of endoscopes
 	quality-assurance testing of endoscopes after cleaning and before high-level disinfection  (e.g., cleaning effectiveness testing)
 	transport of used scopes, transport of processed scopes, storage of scopes
 	drying of scopes
 	transport and storage of processed endoscopes
 	transport of HLD endoscopes to the procedure room
Documentation should also include the results of a return demonstration for each task. In addition, the action taken if any return demonstration failed (e.g., whether the employee was retrained, dates of retraining, by whom, when the second return demonstration was performed, and the results.) Another piece of documentation that is critical is the employee’s annual competency verification for processing activities.
According to ANSI/AAMI ST-91, annual competency verification is “an activity designed to substantiate or confirm the ability of an individual to complete a particular skill, task, complex series of tasks, or behavior necessary to perform effectively.”
Competency assessments should include the following:
 	competencies for every make and model of endoscope
 	transport of used scopes (including documentation of when point-of-use treatment was performed)
 	use of PPE when handling used scopes (including donning and doffing)
 	compliance with manufacturer’s IFU for cleaning
 	use of specific cleaning brushes/equipment recommended in the IFU
 	leak testing/documentation of test results
 	verification of leak tester’s accuracy/documentation of results
 	selection and use of detergents
 	manual cleaning/inspection
 	automated flushing devices (if used)
 	drying/inspection of scopes
 	use of the high-level disinfectant, including MEC testing of the solution before use (if applicable)
 	manual HLD (if applicable)
 	use of the automated endoscope reprocessor (AER) including interpretation of printout
 	use of cleaning effectiveness testing tool with documentation of test results
 	transport of disinfected scopes
 	storage of scopes
 	transport of HLD scopes to the procedure room
Compliance with Stated Policies
It’s one thing to have policies referenced to current standards and guidelines, but are staff members always following those policies? There is no excuse for noncompliance with an endoscope reprocessing policy. Each step in the IFU must be followed to ensure a safe device for the patient. To ensure staff compliance, random audits should be performed, including verification of compliance with the manufacturer’s instructions. This can be done via observation and questioning.
Also, audits can be performed to verify compliance with stated policies. For example, monitor transport of used scopes, documentation records for accuracy, etc. AAMI, as well as other professional organizations, recommend that annual risk assessments be performed to determine needed areas of improvement.
Summary
Endoscope processing personnel need to be kept updated. Encourage your processing staff to achieve certification in flexible endoscope reprocessing and to keep updated in new practices and standards. Encourage competence by supporting their attendance at seminars/webinars. All staff members who attend conferences or webinars should be required to provide
a summary of the information disseminated at the educational program, so the remainder of the staff benefits as well. Virtually all continuing-education programs offer CE credits which support recertification efforts for processing staff.
We have a moral obligation to patients to provide the best care based on the most current national standards and guidelines. It is your responsibility. Get involved! Develop policies and procedures based on these standards and guidelines. Provide in-service opportunities for staff regarding policies and procedures that have been developed or updated. Review your processing policies on a routine basis.
Perform audits to ensure staff compliance with your policies. It’s important to remember that when you don’t comply with a stated policy, you can be found negligent. So, who is processing your endoscopes? What is their competency level? Were they given the tools to provide a patient-safe scope? As W. Edwards Deming said, “Learning is not compulsory; it’s voluntary. Improvement is not compulsory; it’s voluntary. But to survive, we must learn.”
 

### TechTalk: Clearing Up Confusion
As a sterile-processing professional, I’m often asked, “Which standards or guidelines should I follow in endoscopy?”
It’s no wonder people get confused when there are so many healthcare organizations that develop guidelines for endoscopy, such as the Association for the Advancement of Medical Instrumentation (AAMI), the Association of peri-Operative Registered Nurses (AORN), the Society of Gastroenterology Nurses and Associates (SGNA), the Association for the Practitioners in Infection Control (APIC) and multi-society guidelines, among others.
People often want to know which to follow in their practice setting. It has been my experience that most facilities follow guidelines developed by the professional organization to which they belong. In a hospital setting, the operating-room staff most likely will follow AORN’s guidelines for processing  flexible  endoscopes,  while  the  endoscopy department will follow SGNA. Much of the content of various guidelines have similar recommendations, but there can be practices not covered in the guidelines or that are in contrast to guidelines from another organization.
According to the National Institute of Health (NIH), “U.S. Standards  are  authoritative  statements  that  articulate minimal, acceptable or excellent levels of performance or that describe expected outcomes in health care delivery, biomedical  research  and  development,  [healthcare] technology,  or  professional  [healthcare].  Guidelines are  statements  of  principles  or  procedures  that  assist professionals in ensuring quality in such areas as clinical practice, biomedical research, and health services. Practice guidelines assist the [healthcare] practitioner with patient care decisions about appropriate diagnostic, therapeutic, or other clinical procedures for specific clinical circumstances.”
Healthcare professionals utilize the guidelines from their respective organizations to guide their practice. Often these practices relate to clinical matters. However, there is a difference between the two.
Standards
According to the Association for the Advancement of Medical  Instrumentation,  requirements,  specifications, guidelines or characteristics can be used consistently to ensure that materials, products, processes and services are fit for their purpose. AAMI develops standards documents
aimed at enhancing the safety, efficacy, safe use and management of medical devices and health technologies (www.AAMI.org).
AAMI  is  not  a  regulatory  agency  and  its  standards are  voluntary.  AAMI  committees  that  develop  these standards consist of representation from both industry (manufacturers) and users (healthcare professionals from agencies such as HSPA, APIC, AORN and SGNA). Each committee is cochaired by a manufacturer representative and a user representative. In addition, the Food and Drug Administration (FDA) has representation on every AAMI committee to provide additional guidance when documents are being developed.
There is an opportunity for members to communicate their concerns to manufacturers and to learn the science behind the products and processes. For example, for a very long time, users asked for ultrasonic cleaners with greater capacity. It took a while, but now most ultrasonic manufacturers offer multilevel sonic machines.
When a document is developed, a proposal for a new document must be submitted by a member in good standing. Then the need for the new document is distributed to the members to determine if there is a need for this document. If the majority feel the document is needed, a call for committee members is made.
The committee members develop the document over a period of time (depending on the topic, this can take two years or more). A new document might take longer to develop. At each committee meeting (regular meetings are held each spring and fall) the progress on the document is discussed and reviewed by all members. Comments regarding content are submitted in writing and designated as technical or editorial.
However, all comments are discussed and either accepted, accepted with modification, or not accepted. This review process continues until the document is completed and all comments have been resolved. Then the document is placed out for ballot by the committee members. A majority of votes are needed to pass. If passed, the document is then reviewed by the public for comments. Following the successful comments/approval process for the public review, the document is sent to the AAMI board of directors for its review/approval. Since the document is a standard, it also needs approval from the American National Standards Institute (ANSI).
Then the document is known as ANSI/ AAMI [title of the document]. Standards always have a ST designation and a number as part of the document’s title (e.g., “Flexible and semi-rigid endoscope processing in health care facilities,” ST-91 2021). All standards are reviewed every five years and either reaffirmed (document still needed but no changes are needed); discontinued (no longer relevant), or needs updating (with changes).
Of Note …
Like  standards  and  recommended practices, an AAMI technical information report (TIR) addresses a particular aspect of medical technology. However, a TIR differs markedly from a standard or recommended practice in terms of the process followed leading up to publication. This process of consensus is supervised by the AAMI Standards Board and, in the case of American National Standards, by the ANSI. A TIR is not subject to the same formal approval process and reflects primarily a technical committee opinion rather than a national standard.
Summary
I believe there should be standardization of practices for endoscopy regardless of the clinical setting. For clinical issues, clinical guidelines excel, as they are specialty-specific. However, when it comes to processing, that is where the confusion comes in, and confusion has no place in healthcare. If a national standard carries more weight than a clinical guideline, then how can we justify not following it?
According to an American Journal of Law article, “What we are learning, however, is that, in addition to varying in scope and quality, many CPGs [clinical practice guidelines] (such as those created for utilization review by payors or those promulgated by specialty societies, which may conflict with other specialty societies’ standards) are designed to meet the needs of the drafting organization, rather than defining a specific, applicable standard of care for every case.
“This has complicated the adoption of CPGs in establishing the standard of care in particular cases.”
In my opinion, when developing policies relating to care, handling and testing of endoscopes, AAMI ST-91 should be the reference for the reprocessing protocols since it is a national standard. Having more than one reference in a policy is acceptable and, in this case, recommended.

### ‘Never a Dull Moment’
At Advocate Good Samaritan Hospital in Downers Grove, Illinois, endoscopy All Star Dr. Ravi Prakash creates a trusting and supportive environment by understanding and prioritizing patients’ individual needs. Beyond his clinical expertise, he is a champion for the adoption of advanced medical  technology  and  understands  that  traditional methods alone are outdated, given the rapid evolution of modern healthcare.
The hospital offers roughly 30 endoscopy bays for prep and recovery and four procedure rooms, and Dr. Prakash and his team offer a comprehensive range of endoscopic procedures, including EGDs, colonoscopy, ERCP, and EMR/ESD, among many other procedures.
Dr. Prakash is supported by a team of four technicians and roughly 10 procedural nursing staff members. He fosters team cohesion through dedicated initiatives focused on the comprehensive education and training of his collaborating staff.
His patient-centric philosophy means Dr. Prakash has a strong commitment to staying at the forefront of medical technology, and leverages tools like confocal laser endomicroscopy (CLE) as an invaluable adjunct to enable more accurate diagnosis and treatment of esophageal and gastric disorders.
One area where his expertise greatly excels is in radiofrequency ablation (RFA) for Barrett’s esophagus. By combining RFA and CLE with his thoroughness and attention to detail in the proceeding follow-up, he ensures earlier intervention and more optimal outcomes for his patients across their entire treatment journey.
Even amid high-intensity situations, Dr. Prakash says he tries to consistently maintain a calm attitude and composed manner, thereby cultivating a notably positive and stable environment for his staff.
Carmen Covarrubias, GI technician, said Dr. Prakash actively involves his staff during cases. “He goes above and beyond with his patients and staff, and he is very well respected amongst his colleagues,” Covarrubias said. “Dr. Prakash is a resource for many of his staff members, providing information and perspective on various different topics.”
Dr. Prakash is certified by the American Board of Internal Medicine, Gastroenterology. He completed his residency at MetroHealth Medical Center. Dr. Prakash has expertise in treating colonoscopy, upper GI endoscopy, gastroenteritis, among various other conditions, which makes him highly recommended by patients, one of whom wrote, “Dr. Prakash is a kind and trusted practitioner and I appreciate the thorough, thoughtful dialogue we had during my appointment.”
Over its nearly 40-year history, Advocate Good Samaritan has evolved into a recognized national leader in healthcare. The hospital earned a Crystal Award from Truven Health Analytics in 2014 for being named to the 100 Top Hospitals list five times. It also is the only healthcare organization in the state to earn the prestigious Malcolm Baldrige National Quality Award, achieving the honor in 2010.
Awards are just part of what makes working for Advocate Good Samaritan Hospital’s endoscopy team an interesting experience. According to Covarrubias, “There is never a dull moment when working in Dr. Prakash’s procedural rooms.”

### A New Chapter in SGNA Education
On behalf of the Society of Gastroenterology Nurses and Associates (SGNA), I am thrilled to share exciting news about an educational opportunity launching this summer: the SGNA Virtual Symposium, taking place August 8–9, 2025.
Previously known as the Annual Course Virtual Component, this event has been rebranded as the SGNA Virtual Symposium, better reflecting its identity as a distinct, stand- alone educational offering. The change underscores SGNA’s ongoing commitment to providing unique education that meets the evolving needs of our members and the broader GI nursing community.
While the name is new, the format and purpose of the event  remain  the  same—delivering  high-quality,  stand-alone content that complements, but never overlaps with, the in-person annual course. This rebranding highlights SGNA’s commitment to offering timely, relevant education throughout the year that meets the diverse needs of our community.
Over two impactful days, attendees will have access to 10 dynamic sessions focused on some of the most pressing and trending topics in GI care. You’ll hear from leading gastroenterologists and subject-matter experts as they share the latest insights on:
 	GLP-1 medications and their implications for GI practice
 	Colon-cancer screening and prevention
 	Liver diseases and advancements in care
 	Sedation best practices
 	Extracorporeal shock wave lithotripsy (ESWL) and endoscopic retrograde cholangiopancreatography (ERCP)
 	Celiac disease
 	Pelvic floor dysfunction
 	ATP testing and clinical applications
Whether you're looking to deepen your knowledge, earn accredited continuing-education credits, or stay on the cutting edge of GI care, the SGNA Virtual Symposium offers 10 contact hours and unmatched educational value—all from the convenience of your home or workplace.
Registration will open in early June, so stay tuned for updates and mark your calendars. I look forward to seeing many of you online this August as we come together to learn, connect
and advance the specialty of gastroenterology nursing.

### AfterCare: Re-Learning Happiness
“Now and then it’s good to pause in our pursuit of happiness and just be happy.” ~ Guillaume ApollinaireOver the course of my gastrointestinal career, I have been honored to speak at roughly 20 SGNA conferences on various topics, either keynoting or as a breakout. Thirteen years ago (that was 2012; good heavens!), I presented “Happy People Don’t Get Sick: The Link Between Joy and Health.”1 As I’ve recently had free time on my hands with surgical recovery,2 I have gained unstructured time to delve back into that topic.Coincidentally, a group at my alma mater, the William & Mary Society of 1918, sponsored a Zoom conference on “The Science of Happiness” last week. The stars had aligned, and I was delighted to virtually attend. The keynote speaker was the amazing Alexis Franzese, associate professor of sociology and chair of the department of sociology and anthropology at Elon University, who achieved the daunting task of distilling a 15-week/one-semester course into a one-hour Zoom—the whirlwind data dump was fabulous!“My message to women: Do what makes you feel good, because there’ll always be someone who thinks you should do it differently. Whether your choices are hits or misses, at least they’re your own.” ~ Michelle ObamaFranzese led an interactive session with superior skill in post-COVID Zoomland, asking the retirement-age, alumni women participants to define “happiness.” Our definitions ranged  from  “contentment”  to  “pleasure,”  with  “life satisfaction,” “joy,” and “subjective well-being” also making the list. On defining what we considered to be “the good life,” participants differed.The answers included:Friends/connection/familyLove/pleasurePhysical wellness/lack of limitationsExposure to sunshine/natureLaughing out loudWhat is your good life? Take a moment to contemplate. It works better if you choose a lane.“When people feel insecure about something, they look around for validation. Show them that other people trust you.” ~ Francisco RosalesFranzese described the differences on a spectrum between hedonic happiness (all of one’s time spent in the pursuit of self-pleasure) to eudaimonic happiness (gaining happiness via virtuous actions). And yes, I believe that most in healthcare are driven by eudaimonia—caring for others to validate and support our own happiness and self-worth. Franzese noted how our current society and our nation’s youth have been aggressively marketed into believing in hedonic happiness, the pursuit of newer and cooler stuff that marketers promise will allow us to finally purchase and achieve happiness. We are now extensively trained by marketers and a culture whose purpose is to show us what we should want to achieve fulfillment.Have you become lost in today’s hedonic marketing trap?“I didn’t have any accurate numbers so I just made up this one. Studies have shown that accurate numbers aren’t any more useful than the ones you make up.”“How many studies showed that?” “Eighty-seven.” ~ Dilbert, by Scott AdamsBeing  100%  happy  is  a  pathological  state;  Franzese suggests a more reasonable target is 70%, with occasional highs and lows. Of your own baseline happiness, 50% is based on genetics, 40% is your own governance by choice or behavior, and 10% is due to life circumstances. The final 10% tends to be transient; even in illness or trauma, that 10% resets to baseline, as has been seen in studies of folks who’ve suffered a traumatic hemiplegia. That means that even in times of scary current affairs with the locus of control seemingly out of our reach, that 40% remains under our own control.“For once, I’d like to spiral into control.” ~ Unknown So what infringes on your personal mellow and interferes with your happiness and control of that 40%? Is it not enough free time and “me time”? Would you like to simply feel “whelmed” occasionally, neither over nor under?We each need to choose to be happy in the now—not waiting for the stars to align to an excellent intimate relationship, a 20-pound weight loss, good health, sanity in government, and/or a new car or house.We  get  stuck  in  indecision,  believing  that  focusing, correcting or obtaining one new thing will cause our happiness  (that  hedonic  happiness  from  earlier),  or  a decision-paralysis cycle, akin to going to a restaurant with a multipage menu—“Please just tell me your three best-reviewed dishes and I’ll choose one of those.”“You have chosen…wisely.” ~ Indiana Jones and the Last CrusadeWhat can you choose to do, today, to increase your happiness? Several simple and free actions have been found to bolster that personal 40%.First, please don’t get trapped in decision paralysis here, just choose one action that you can implement. Two, perhaps, if you’re an overachiever.Schedule unstructured time for yourself.Give to others, even simple thanks and gratitude.Do 20 minutes of cardio exercise three times a week, preferably in nature.Identify your happy place to visit daily. Your happy place can be real or imagined, it could be by water or a beach, in a garden, listening to a joyous mix tape, a cozy nook in which to read, a memorable smell that returns you to a moment of childhood bliss. Be authentic to yourself with your happy place; it need not compare with others’.“There’s never enough time to do all the nothing you want.” ~ Calvin & Hobbes, by Bill WattersonAll too quickly, the one-hour whirlwind was over, followed by concurrent sessions on happiness through mindfulness or through art therapy. In the art-therapy session, we learned to register and then artistically recreate “glimmers” we had experienced that day; the opposite of a traumatic trigger, a “glimmer” is something that brings fleeting happiness and joy. We learned to capture our glimmers through decidedly imperfect art, and to reinforce and to seek glimmers daily.“Cherish the glimmering moments, for they are the ones that will light up your memories.” ~ UnknownNotes:The non-animated version of my 2012 happiness presentation, done on a software called Prezi, remains available at https://prezi.com/view/JFyvPqf4Eb5H2UfBSnhN/. The data is still accurate.I’m doing great now after left total-knee replacement January 24, 2025; I was recently released from six weeks of homebound/home physical therapy. Now starting outpatient PT for at least an additional six weeks. (If you’ve been on the knee fence, just do it!)

### Prior Authorization
No one has given me prior authorization to rail on prior authorization, but I’m going for it anyway. Oh, insurance companies, how I don’t love thee. Warning: in this letter I’m going to exhibit significant bias against insurance companies. If you’re into that, read on! However, if big insurance companies are your jam, you might want to skip this letter.It’s not an understatement to say that I hate insurance companies. (My late father’s words are echoing in my ears now; I hear him saying, “Hate is a very strong word.” So let me weigh this memory before using the term ... Okay, I weighed it and—sorry, Dad—I do indeed hate insurance companies). But there is no small irony in including my dad, since:I’m on a commercial flight (I’m headed to the Healthcare Sterile Processing Association conference) and my dad died on a commercial flight.If it weren’t for insurance companies being selfish cheapskates, my dad could very well still be alive.In 2006, Dad died of a heart attack. He was 51. I was 25. The autopsy determined his problem would have been detected by a specific test that his insurance covers at age … 53. He had considered getting that test, but since he seemed to be in decent health, he didn’t want to incur the enormous out-of-pocket charge. Had he found out what was wrong he would have taken immediate and serious steps to reduce stress and eat even better. I know this to my very core. Another insurance irony here (and for me a tragedy, because it all led to losing Dad way too young) is that stress was a major contributor to his heart attack, and guess what his biggest stressor was? The fact that he was working two jobs because he needed insurance. He was in business for himself as a pressure washer, and he had a job on the side, driving for a nursing home.My dad worked hard his entire life and lived frugally, yet the truth is impossible to ignore: He needed two jobs to secure insurance and make enough money to survive. We all know people in this position. Some of us may be in this position right now. And these days, people have it much harder than when Dad died in 2006, since the cost of living has gone up exponentially, while salaries haven’t kept pace. It sure isn’t getting any easier to be a middle-class person in the United States. One of the last things my dad ever said to me is, “The rich are gonna keep getting richer.” Boy, was he right.The reason I initially chose this topic—before I got pretty damned sad and frustrated thinking about my dad—is that one of the many injustices of our modern national healthcare insurance cluster-mess is the concept of prior authorization. The American Medical Association released a great opinion article on this topic recently. It’s titled, “Don’t Fall for These Myths on Prior Authorization,” by Tanya Albert Henry. (See blue section below for article).According to Henry, “Knowing the truth is important because prior authorization, a utilization-management tactic that in- surers once reserved for extremely expensive intervention, is now employed for even the simplest generic medication. And denials only seem to be becoming an even greater problem for physicians and patients’ health. A recent AMA survey shows that 61% of physicians fear payers’ unregulated use of AI tools will increase prior authorization denials. The payers’ automat- ed decision-making systems create systemic batch denials with little or no human review.”I often wonder how big a headache the average endoscopy facility staff considers insurance to be. What’s your facility’s relationship with insurers? I imagine it’s not a one-size-fits-all situation—indeed, some insurers must be worse than others in what they’ll approve and in how they communicate. This is surely true of prior authorization as well.Henry wrote, “Behemoth health insurers claim this time-wast- ing practice improves care and saves everyone money. Look beyond the myths and find out the facts. …Patients and phy- sicians beg to differ with the claims that insurers bandy about when discussing payers’ time-wasting, care-delaying tactics that are designed to control costs. And physicians have the research to back up their position.” AMA leaders aren’t sitting around complaining like I am; they’re taking action.AMA is challenging insurance companies to eliminate care delays, reduce patient harm and decrease inconvenience to practices. “That includes setting the record straight on what the research shows about how prior authorization is used and how it affects American healthcare,” Henry wrote. A large section of her article is printed below, wherein Henry does a great job comparing fact and fiction with it comes to prior authorization.Myth: Prior authorization lowers costPrior authorization, in fact, does not lower costs. Drug prior authorization costs $93.3 billion annually, according to a study published in Health Affairs. No one is immune. The study estimates that prior authorization costs payers$6 billion, manufacturers $24.8 billion, physicians $26.7 billion and patients $35.8 billion annually.Meanwhile, 88% of physicians surveyed by the AMA reported that prior authorization leads to higher healthcare utilization because of avoidable emergency department visits and patients being forced by payer policies to initially use ineffective treatments.Fact: It’s expensive for doctors—and payersHere’s what some researchers have discovered about how prior authorization translates in economic terms for physicians and payers.For primary care physicians, prior authorization costs an individual doctor between $2,161 and $3,430 annually, according to a study published in the Journal of the American Board of Family Medicine.At 11 dermatology clinics that researchers examined, completing a prior authorization for biologic drugs cost an average $15.80 per request—or about $3,454.15 for the month studied, according to research published in JAMA Dermatology.Emergency visits and hospitalizations rose 1.7 percentage points when access to antidepressants was restricted, according to research published in Forum for Health Economics and Policy.Formulary  restrictions  on  antipsychotics  increased hospitalization risk, inpatient costs and total medical costs, according to a study of 24 state Medicaid programs published in the American Journal of Managed Care. Restrictions increased the number of incarcerated people by 9,920 and upped the costs associated with incarceration by $362 million nationwideMeanwhile, if a “gold carding” program—a system that allows approved physicians to forgo prior authorizations for certain medications or procedures—were implement- ed, it would save 5%–10% for payers and physicians, a McKinsey & Co. analysis found.Fact: Prior authorization is wastefulThe AMA’s most recent annual survey of 1,000 physicians about prior authorization found that practices on average complete 39 prior authorization requests per physician, per week.The AMA survey (PDF) also found that:Physicians and their staff spend an average of 13 hours completing those requests each week.40% of physicians have staff who work exclusively on prior authorizations.After jumping through all of those hoops, 98.5% of prior authorizations in pediatric oncology and hematology were eventually approved, according to a study in the Pediatric Blood & Cancer journal. Similarly, an AMA-funded cohort study published in Arthritis Care & Research found that 96% of all prior authorizations on rheumatoid disease treatments were ultimately approved.Myth: Prior authorization improves careThe opposite is true. Prior authorization worsens patient outcomes.Insurance companies’ overuse of prior authorization causes patients real harm — in some instances even resulting in death. Nearly 30% of the physicians who participated in the AMA prior authorization survey reported that the practice has led to a serious adverse event for a patient in their care, including 8% that said prior authorization led to a patient’s disability or permanent bodily damage, congenital anomaly or birth defect or death.Fact: It delays necessary careIn addition to the agonizing anecdotes that every physician has, numerous peer-reviewed studies back up the fact that prior authorization results in patients not getting necessary care as quickly as they should be getting it. Here are a few examples.Reduced access to novel anticoagulants because of prior authorization and step therapy led to higher risk for mortality,  stroke  and  transient  ischemic  attack, according to research published in The American Journal of Managed Care.In an American Society for Radiation Oncology survey, 31% of radiation oncologists said that prior authorization had delayed a patient’s treatment by one week, alarming because other research has shown an association of “each week delay in starting cancer treatment with a 1.2% to 3.2% increased risk of death.”Dermatology patients with approved prior authorization requests had a 71.1% likelihood of disease improvement; those who had requests denied had a 58% likelihood of improvement, says a study published in the Journal of the American Academy of Dermatology.Fact: It blocks evidence-based carePhysicians spend many years in medical school, residency and fellowship training and continuing medical education to gain the knowledge and skills needed to provide the best care for patients.Yet prior authorization decisions are frequently made by those who do not share those qualifications. When physicians have “peer-to-peer consults,” the person on the other end of the line may be a nurse or a physician in a completely different specialty with little to no knowledge of the disease or treatment in question.In addition, research has shown that prior authorization has led to:A nine-times increased likelihood that irritable bowel disorder patients will need surgery when medication has been denied through prior authorization, says a study published in the journal Inflammatory Bowel DiseasesOver 40% of commercial patients and 53% of Medicare patients not beginning the oncology treatment their physician prescribed after a prior authorization denial or step therapy requirement, according to a white paper published by IQVIALimited access to pre-exposure prophylaxis (PrEP) and increased rates of HIV diagnosis in regions with high rates of prior authorization for PrEP, which protects against contracting HIV, according to a JAMA Network Open studyIf you’d like to learn more about what healthcare teams and patients can do to help reform efforts, or if you’d like to share personal experiences with prior authorization, contact FixPriorAuth.org. I’m going to take part in the reform, in honor of my dad. I’m still typing on a plane like I was at the beginning of this letter, and I’m still thinking of Mark Beaver in a way that, if I delve deeper, will make me cry. He took his final breaths in an airplane cabin just like I’m in right now. I’ve always wondered if I’d ever meet someone who was on that flight from Albany, New York to Sarasota, Florida. Who knows—maybe one of you were on that flight or knew someone who was. The plane emergency-landed in North Carolina, but it was too late. Dad left the plane in a body bag.That’s not a flight anyone on board would ever forget, and I’ll never forget that had it not been for the penny-pinching, wildly rich misers at insurance companies, my father probably would have lived a lot longer. I can never condone that Luigi Mangione killed UnitedHealthcare CEO Brian Thompson—the murder was wrong; it was sick and cruel— but I can understand the rage he felt, and I suspect many of you may understand that rage as well. I’d love to ask my dad his thoughts on all this, but I can’t. He’s gone. And so, I’ll ask you, as a healthcare professional whose practice deals with insurance, for your thoughts instead. Please feel free to email me at michelle.beaver@endopromag.com.Note: As we go to press the last week in May, 2025, our senior editor is still trying to get an urgent medication prescribed in late April by her doctor. Her insurance company kicked it back for—you guessed it—prior authorization.

### Endoscopy Devices Market Growing Exponentially
According to a new report published by Polaris Market Research, the endoscopy devices market size was valued at USD 60.94 billion in 2024. It is estimated to reach USD 87.41 billion by 2034, registering a CAGR of 3.68% from 2025 to 2034.
Endoscopy devices are adaptable tools that merge fiber optics and charge-coupled devices to provide illumination and visualization of otherwise unapproachable sites such as the lumen of vacant organs. An endoscope comprises a tip, an insertion tube, and a control section. Modern endoscopes are competent of offering high definition, high clarification images that can be enhanced to inspect the mucosa more comprehensively.
The most commonly used endoscopic instruments are gastroscopes and colonoscopes, which are used to examine the upper gastrointestinal tract and colon, respectively. Therapeutic endoscopes with large channel diameters, allowing the passage of complex and advanced accessories, are also available for advanced interventional procedures. Specialized endoscopes can be used to inspect the small bowel, biliary and pancreatic ductal systems, as well as extra-luminal anatomy.
The growing existence of detrimental illnesses is a prominent driver of the market as conditions such as cancer, gastrointestinal disorders, and cardiovascular illnesses growingly need early and precise diagnosis. A December 2024 WHO report propounded that noncommunicable illnesses led to 43 million deaths in 2021. This rise in chronic illnesses is driving the endoscopy devices market demand.
Progressions in endoscopy devices play an important part in accuracy, safety, and practicability of the devices. Inventions such as high-definition imaging, flexible endoscopes, and robotic-assisted have augmented the gamut of clinical applications for endoscopy, enabling more precise diagnostics and minimally invasive surgeries.
Endoscopy Devices Market Report Highlights
• In terms of devices type, the endoscopes segment held the largest market share in 2024, given their essential role in diagnostic and therapeutic procedures across medical specialties.
• Based on end-use, the hospital sector is anticipated to expand significantly due to its advanced infrastructure and capacity to support complex endoscopic procedures.
• North America led in market revenue share in 2024, attributed to its robust healthcare systems and early adoption of innovative endoscopic technologies.
The Asia Pacific market is expected to grow the fastest, fueled by improving healthcare access and increasing investments in medical infrastructure. Major players have adopted strategies such as product instigation, agreement, product consent, and augmentation to improve their product portfolio.
Major companies are:
• Arthrex, Inc.
• B. Braun Melsungen AG
• Boston Scientific Corporation
• Cook Medical
• Fujifilm Holdings Corporation
• Hoya Corporation
• Johnson & Johnson
• KARL STORZ SE & Co. KG
• Medtronic plc
• Olympus Corporation
• PENTAX Medical
• Richard Wolf GmbH
• Shanghai Aohua Photoelectricity Endoscope Co., Ltd.
• STERIS
• Stryker Corporation
North America dominated the endoscopy devices market in 2024 due to the region's excessively advanced healthcare framework and early adoption of progressive medical technologies. Asia Pacific is projected to witness the fastest growth due to enhancing the healthcare framework and growing healthcare disbursement covering emerging economies.

### Olympus Launches New Endoscope Drying Cabinet
Olympus Corp.—A global medical technology company—in late May announced the launch of the Olympus endoscope drying cabinet, known as the ScopeLocker Air, offering a new drying option for healthcare facilities.
Drying endoscope channels is a critical component of reprocessing. The Olympus endoscope drying cabinet, manufactured by Capsa Healthcare and distributed by Olympus Corp., helps facilitate the drying process and is designed to meet society guidelines for endoscope drying and storage.
With this new model, multiple size and material options are available to meet facility needs. The 41-inch-wide Olympus endoscope drying cabinet can accommodate up to 18 endoscopes, while the 22-inch-wide cabinet ideal for smaller facilities such as ambulatory surgery centers can accommodate up to eight endoscopes. Powder-coated steel and stainless-steel options are available for all models.
Providing continuous airflow through channels and around the outside of the endoscope, the Olympus endoscope drying cabinet aids in the reprocessing cycle by providing an air source option that is built into the cabinet. According to Olympus, this latest version improves the ScopeLocker with HEPA storage cabinets that healthcare facilities have been using for years by adding air manifolds, autoclavable connectors, and HEPA-filtered air pumps into the top of the cabinet for additional space efficiency. Facilities can also choose to use their own air source.
Other features of the ScopeLocker Air include:
 	Rotating scope holders for easy access to the second row of endoscopes
 	An air manifold designed to easily connect up to 18 scopes
 	A padded lower back wall designed to protect the distal tip of an endoscope with optional side padding available
 	A center separator scope rack designed to keep scopes from touching during storage
 	Optional electronic keyless entry for all cabinet options
 	Optional LED lighting.
“Patient safety is at the center of all we do, and this newest Olympus endoscope drying cabinet is part of a larger infection prevention portfolio and strategy to help facilities address their reprocessing needs,” said Patrick Romano, Vice President, GI Business Unit Leader, Olympus Corporation of the Americas.
 

### Cedars-Sinai Study Shows How Specialized Diet Can Improve Gut Disorders
A new study from Cedars-Sinai examined whether a specialized diet could improve symptoms of gastrointestinal disorders linked to an imbalance in gut microbiota.
The research tested the elemental diet’s effectiveness and explored whether improving its unappealing taste—a major barrier—could help patients adhere to the diet’s stringent protocol. The investigators’ findings were published in the peer-reviewed journal Clinical Gastroenterology and Hepatology.
The elemental diet is a special low-fat liquid formulation that is designed to be easily digested and contains all the essential nutrients necessary for a healthy diet. A few prior studies have shown that the diet has the potential to improve challenging symptoms associated with digestive issues like small intestinal bacterial overgrowth (SIBO), intestinal methanogen overgrowth (IMO), Crohn’s disease, eosinophilic esophagitis and other gut ailments. The diet likely works by reducing inflammation, balancing the gut microbiome, healing the gut lining, and providing complete nutrition without additives and allergens that typically irritate the gut. Historically, elemental diet has had a low adherence rate because of the strict protocol and unpleasant taste.
SIBO and IMO typically occur when harmful bacteria or methane-producing microbes grow out of control in the gut. While antibiotics are often used to treat these conditions, they don’t always work.
“Elemental diets are designed to give the digestive system a break by providing easily absorbed nutrients,” said Ali Rezaie, MD, the study’s corresponding author and medical director of the GI Motility Program and director of Bioinformatics at the Medically Associated Science and Technology (MAST) Program at Cedars-Sinai. “This reduces stress on the gut, helping it heal and function better.”
In this study, 30 adults ages 18 to 85 diagnosed with SIBO or IMO strictly adhered to only a more palatable version of the elemental diet for two weeks. This was followed by two weeks during which study participants resumed their normal diet. The researchers analyzed changes in the gut microbiome, how well the diet was tolerated, symptom relief and breath test results, along with tracking any side effects.
The results were encouraging. Most participants reported tolerating the diet well, with no serious side effects. A key finding was a reduction in unfavorable microbes linked to gut issues. Methane levels also dropped significantly, with many returning to normal.
In addition, 83% of participants reported feeling better, with significant relief from common symptoms like bloating and discomfort. These findings suggested that a tastier version of the elemental diet helped restore balance in the gut and eased symptoms of SIBO and IMO.
“The study's positive results suggest that enhancing the palatability of the elemental diet could make it more accessible and practical for patients, improving adherence and quality of life for those who face significant challenges with traditional therapies,” said Mark Pimentel, MD, study author and executive director of the MAST Program at Cedars-Sinai.
Rezaie and his team of investigators plan to conduct larger studies to better understand the long-term effects of elemental diets and further address the socioeconomic barriers.
 
 
 

### The Ups & Downs of Hydrotherapy
Hydrotherapy has been the butt of a lot of jokes.
Okay, thanks for letting me get that out of my system. So to speak.
We all know bowel prep is the critical factor in ensuring a successful colonoscopy. So much so, there’s a rating system for it: the Boston Bowel Preparation Scale (BPPS). (You have to wonder who drew the short straw to decide exactly how much fecal matter determined the “degree of soiling” level?) In the BPPS, the bowel is divided into three sections—right colon, transverse colon, and left colon—and then further segmented by degree of soiling. First published in 2009 by Edwin Lai and associates, the BPPS was part of a 2016 systematic review of colon-cleansing scales—including Ottawa Aronchick and Harefield, among others. Authors Robin Parmar and associates concluded that “The BBPS is the most thoroughly validated scale and should be used in a clinical setting.” The scale now is used and accepted worldwide.
But let’s face it: Scale or no scale, patients hate colonoscopy bowel prep. They just do. The uncomfortable, undignified process has become fodder for objectors and comedians alike. And who can blame them when side effects can include nausea, vomiting, bloating and, in some cases, increased hemorrhoidal flare and loss of sleep? But the success of a colonoscopy depends heavily on how well the patient follows prep instructions.
If the patient is indifferent, well—crap gets in the way of the exam. In a 2022 prospective observational study, Niels Teich and associates wrote, “Patients often consider [bowel prep] to be the most burdensome part of colonoscopy, which might be a main barrier to the procedure.” Some people simply refuse to schedule their colonoscopy—all because of what they’ve heard about the prep.
Hydrotherapy is a method of cleaning out the colon working from the bottom up, rather than the top down, by irrigating the colon with warm water. In some cases, massage is introduced to help loosen fecal matter. According to ColonicsDetox, based in the United Kingdom, the method has been in practice for thousands of years, with origins in Egypt, Greece and India. “It is an integral part of a modern naturopathic approach to health and was used in hospitals until the 1970s. The ultimate detox, it’s a very safe and gentle treatment,” the website states.
Teich, et al., wrote, “... bowel cleansing quality of colonic irrigation is considered comparable to oral purgative [regimens] but with less side effects and high patient satisfaction.” The study examined the efficacy of colonic irrigation as a method of bowel prep, using a new colon hydrotherapy device. They found the device to be “an effective and low-risk alternative to traditional oral preparation.”
Trouble in Paradise
The problem with bowel prep isn’t always with patient noncompliance. To put it indelicately, some patients are simply more full of crap. Some patients may have medical conditions that predispose them to problematic prep. And patients are always pressing for a more palatable regimen that includes lower volume.
Cristina Rutherford and Audrey Calderwood wrote in Current Treatment Options in Gastroenterology that between 10% and 25% of patients have “inadequate colon cleansing” on the day of their colonoscopy.
The big question is, why? Were patients noncompliant? Or was the prep inadequate? Practitioners can help facilitate answers to these questions, although this can be tricky: Will a patient hide the truth if she didn’t drink the whole prep? Or will she, like me, admit she had to stop about two-thirds of the way because she came close to vomiting and there was nothing coming out of her but bile, anyway? (Full disclosure: My gastroenterologist said my prep was fine and she had no trouble visualizing.) But I’m an average-sized woman of low weight. Should the same prep be used for me that’s prescribed for a 300-pound man who eats nothing but cheeseburgers?
Nabil Fayad and associates asked that same question in the journal Clinical Gastroenterology and Hepatology. In a 2013 retrospective study, they discovered that bowel prep was inadequate for 44.2% of patients who, it turned out, had “significantly higher mean BMIs” than those for whom prep was adequate. Their takeaway? “BMI is an independent factor associated with inadequate split bowel preparation for colonoscopy,” they wrote. But they also cited additional factors that might affect prep, including “diabetes, hypertension, dementia, and use of tobacco and narcotics. Patients with BMIs ≥ 30 kg/m2 should be considered for more intensive preparation regimens.”
Conversely, a 2019 observational study published in the Journal of Clinical Gastroenterology found no correlation between obesity and bowel prep; instead, the authors cited factors such as male gender, diabetes, liver cirrhosis, coronary artery disease, refractory constipation and current smoking as predictive of poor bowel preparation.
In a 2021 narrative review, Emanuele Sinagra and associates examined a low-volume polyethylene glycol/ascorbic acid solution (PEG-Asc) that might improve patient compliance. But they emphasized that a “one size fits all” prep is not feasible, and “a bowel preparation [regimen] must always be selected and tailored by the clinician for each patient, evaluating the best options on a case-by-case basis.”
Just Add Water
With hydrotherapy, poor prep is no longer a pressing problem. At GI Associates in Mississippi, patients are already enjoying the ease and benefits of hydrotherapy. The FDA-approved HygiPrep system allows the patient to be treated in a private room during the process. While seated in a sanitized basin, the patient inserts a sterile, disposable nozzle into the rectum, and a gentle stream of warm water is introduced, which loosens fecal matter and cleans the colon. Sanitary and odorless, the process takes less than an hour.
Possible side effects of the procedure can include cramping, dizziness, nausea and vomiting, as well as “clinically insignificant rectal abrasians,” according to the online brochure. Other practitioners cite bloating and perianal soreness, electrolyte imbalance, bowel perforation, liver toxicity, water intoxication, and infection. In an abstract published in the American Journal of Gastroenterology, Amulya Reddy and associates wrote, “It is thought that increased intraluminal pressure during colonic hydrotherapy results in bacterial translocation into the peritoneal cavity.” And the process isn’t for everyone: patients with congestive heart failure, renal insufficiency or intestinal perforation should not use HygiPrep.
That said, GI practitioners gave the process a 98% approval rating for cleanliness; nearly 2500 patients scored it even higher, with 99% saying the experience was “good” or “very good.”
One of the few controlled studies available on colonic hydrotherapy compared it with a polyethylene glycol electrolyte lavage (PEG-EL) solution. The findings were interesting: While the PEG-EL group had better colonic cleanliness, and fewer adverse effects, which went over well with practitioners, the hydrotherapy group boasted higher diverticulosis detection rates and higher patient satisfaction.
Community Feedback
While we might improve patient satisfaction by splitting the prep solution or going with hydrotherapy, one group that’s not happy with the whole “cleaning out the colon” thing is our microbiome.
The microbiome is a teeming collection of beneficial bacterial hordes that live quite happily in our gut. Without this tiny community, our gut could not function. These “good bugs” help digest our food, balance our immune system, and destroy bad bacteria that cause disease. Most of the beneficial stuff that happens in our small intestine, happens because of the good bacteria; they produce enzymes to break down indigestible carbohydrates, ferreting out the nutrients our body needs. And as you probably already suspect, what we eat has a big impact on our microbiome, with fruits, vegetables and whole grains getting a big thumbs up, but processed foods and those high in fat and sodium, not so much.
In Integrative Medicine: A Clinician’s Journal, Matthew Bull and Nigel Plummer wrote, “Imbalance of the normal gut microbiota have been linked with gastrointestinal conditions such as inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS), and wider systemic manifestations of disease such as obesity, type 2 diabetes, and atopy.” So not only is it important to possess a microbiome—it’s also important to keep the little guys happy and functioning properly.
Amit Gajera and associates noted that patients with IBD must endure frequent colonoscopies because of their higher risk for colorectal cancer. However, the prep often becomes burdensome. “Additionally, oral BP has been noted to possibly induce colon mucosal inflammatory changes in some patients, which may be misleading when assessing actual disease activity,” they wrote. Mucosa visualization is critical to IBD diagnosis, so the disruption of gut mucosa caused by oral purgative-based preps, “especially those containing sodium phosphate,” can skew the exam’s results.
In addition, they argued that mucosa can suffer injury from oral preps, especially those that contain sodium phosphate, “even to the point that it mimics CD.” One of the benefits of HygiPrep is that it does not use mucosa-affecting chemicals. “The prep induced peristalsis as the water gently flows in the gut lumen and naturally loosens the colon content, including that of the ascending (right) colon,” they wrote. “Therefore, this prep is likely to be less disruptive for the bowels of IBD patients and circumvents the disruptive nature of the oral purgative prep while providing a more accurate assessment of disease activity.”
While many practitioners argue that a nice colon cleanse is good for us, our bacteria family—if they could—would claim otherwise.
In a randomized controlled trial, Jonna Jalanka and associates examined two study groups who consumed prep in a single dose or two separated doses. The team examined fecal samples taken for a baseline, after bowel cleansing, and at 14 days and 28 days post-treatment. What they found was that although the patients’ bacterial communities were restored by 14 days, “the rate of recovery was dose dependent: consumption of the purgative in a single dose had a more severe effect on the microbiota composition than that of a double dose, and notably increased the levels of Proteobacteria, Fusobacteria and bacteria related to Dorea formicigenerans. The abundance of the latter also correlated with the amount of faecal serine proteases that were increased after purging.” Cleansing by using two separated doses turned out to be easier on the gut’s microbiota.
No one’s arguing that we should give up colonoscopies. But it’s good for practitioners to be aware of the prep’s impact on our microbiota, especially for patients with IBS, Crohn’s or other conditions that may be negatively affected.
As Gajera and associates wrote, “Using this BP for IBD patients can allow earlier interventions, significantly impacting disease management and future outcomes.” If the procedure increases compliance among IBD patients, it could also do the same among the general population.
The only thing hydrotherapy won’t change is the late-night comedy jokes.

### Advancing to Sterilization
The high infection rate associated with flexible endoscopes remains a significant challenge in healthcare globally despite advancements in reprocessing techniques. Endoscope-associated infections (EAIs) have been a persistent issue, with recent data indicating that infection rates following endoscopic procedures are higher than previously reported. The infection rate for certain endoscopic procedures can be as high as 1 in 1,000.1 Even with improvements in device design, reprocessing methods and equipment, and staff training and oversight, pathogen transmission from persistent contamination of flexible gastrointestinal endoscopes continues to occur.2
Human errors and variability are inevitable and can increase the risk of breaches in the reprocessing protocol. Staffing shortages, coupled with the complexity and length of reprocessing instructions, contribute to increasing time-constrained pressure on healthcare workers. It is imperative for healthcare organizations to use the most effective and robust reprocessing technology to reduce the chances of infection transmission and increase the margin of safety for patients.3
Infection Outbreaks 
Inadequately cleaned endoscopes have been implicated in multiple drug-resistant organism (MDRO) infection outbreaks4 and continue to be reported to the FDA related to patient safety concerns. In cases of outbreaks related to MDROs, the failures in the processing or the equipment were not always identified even though the facilities followed the guidelines and manufacturers’ written instructions for use (IFU).4 “Flexible endoscopes are complex medical devices that require equally complex processes for effective cleaning and sterilization or HLD. Even the most rigorous processing methods can be undermined by the design of the device or contamination of the endoscope during handling, rinsing, drying, transport or storage.”5
Endoscope Design: A Reprocessing Challenge 
The complexity of endoscope design, particularly in devices like reusable duodenoscopes, makes thorough cleaning and disinfection difficult, leading to residual contamination and subsequent infections.6 Reprocessing instructions can be very lengthy and describe more than 100 specific steps for personnel to execute. Current guidelines also do not specify a minimum amount of time required for manual cleaning, leading to wide variations in practice and potentially inadequate removal of bioburden.7
In recent years, most endoscope manufacturers have enhanced duodenoscope designs and brush models to improve cleaning and facilitate access to the intricately designed and hard-to-clean areas such as the distal end. Yet, the long lumens of these devices remain common sources of hidden microorganisms.7
Reprocessing: Increasing the Level of Assurance 
The reprocessing of medical instruments is a critical component in ensuring patient safety in healthcare settings. Two primary methods used to decontaminate medical instruments are high-level disinfection (HLD) and sterilization, both of which aim to reduce the risk of infection transmission. These methods differ in their efficacy and procedures, as well as the level of safety they provide.
High-Level Disinfection vs. Sterilization: What’s the Difference? 
HLD is a process designed to eliminate all microorganisms, except for bacterial spores, which are highly resistant to disinfection.8 HLD typically involves the use of chemical disinfectants and results in a lower margin of safety compared to sterilization. Sterilization, on the other hand, is the most thorough method for eliminating all microorganisms, including bacterial spores, viruses, fungi and bacteria. The process involves exposing instruments to high-pressure steam, gas or hydrogen peroxide vapor.8
The margin of safety decreases when processing flexible endoscopes, especially when using HLD instead of sterilization modalities.5 Evidence to support sterilizing all flexible endoscopes (semi-critical and critical) includes: high microbial load after patient procedure,4 complex design of flexible endoscopes, and risk for biofilm formation.4
Sterilization modalities also reduce the potential risks for an endoscope to become recontaminated post-disinfection. During HLD, the water, pipes and tubings used in automatic endoscope reprocessors (AERs) can potentially harbor harmful microorganisms if not monitored and disinfected routinely. Poor handling techniques post-HLD and during storage are also potential sources of transmission of microorganisms.9 Sterilized scopes are packaged and sealed prior to sterilization, reducing the risk of recontamination.
Sterilization: Elevating the Standard of Care 
The goal of sterilization is to provide a higher level of assurance that all potential pathogens have been eliminated to minimize the risk of healthcare-associated infections (HAIs). As healthcare professionals strive to improve patient outcomes and reduce the incidence of EAIs, there is an increasing call to transition from HLD to sterilization.6 By adopting sterilization practices, healthcare facilities can better protect patients from the risks associated with endoscopic procedures, which contributes to safer and more effective healthcare delivery worldwide.
Sterilizing semi-critical devices enables compliance with Spaulding’s classification. Semi-critical endoscopes that enter a mucous membrane (non-sterile tissue), yet indirectly contact normally sterile tissue or enter the bloodstream, should be classified as critical devices.9 The Canadian Standards and Guidelines have classified bronchoscopes, laryngoscopes, cystoscopes and ureteroscopes as critical devices and have required their sterilization since 2018.10
High-risk endoscopes that have been associated with infectious outbreaks include bronchoscopes, cystoscopes, duodenoscopes, endobronchial ultrasound endoscopes, linear ultrasound endoscopes, and ureteroscopes. These scopes are difficult to process and pose an increased risk of incomplete cleaning of contaminating infectious organisms.4 According to AORN, “Sterilization provides the greatest margin of safety and assurance that the endoscope is safe for patient use. Correctly handled and sterilized items are rarely associated with patient infection.”5 Terminally sterilized endoscopes are rendered completely dry, packaged (which reduces the chance of contamination for longer periods of time), and are patient-ready. Packaged endoscopes have tamper-evident seals that clearly distinguish “used” endoscopes from “patient-ready endoscopes.”4
Culture of Safety 
The Joint Commission has emphasized the importance of creating a culture of safety, notably in the context of medical instrument reprocessing. This culture focuses on reducing variations, reducing risk, and improving patient care with quality management systems.11
In the case of endoscopes, which are among the most used and complex instruments requiring reprocessing, the need for careful documentation and traceability is even more pronounced. With their high level of complexity, improperly reprocessed endoscopes can lead to significant patient harm. In the event of an endoscope-related infection outbreak, the ability to track each step of the reprocessing process is crucial to a rapid investigation and patient protection.12
Terminal sterilization offers a higher quality assurance over other modalities because the level of sterilization is accompanied by quality process monitors that verify the efficacy of the sterilization.13 By aligning the culture of safety, best practices and quality assurance, healthcare facilities can meet the highest standards of safety and quality of care.
Conclusion: Sterilization is the Gold Standard 
Many people will become a patient receiving an endoscopy procedure as part of preventative or diagnostic healthcare in their lifetime. For healthcare providers and personnel who provide endoscopy procedures, there is great satisfaction in supporting patient care through these lifesaving procedures. Endoscopes play a vital role in the effective delivery of healthcare; however, risks associated with unintentional transmission of infectious organisms via endoscopes continue to be a significant concern. The complexity of endoscope design presents a challenge to achieving consistent and effective processing. Although risk-mitigation steps are detailed in manufacturers’ IFU, these steps fail to account for the high-risk design elements, such as long, internal lumens and recessed spaces that either cannot be visualized or are difficult to visualize.4
The process of improving patient safety in flexible endoscopy requires clear guidance on endoscope processing, effective training and competency verification of personnel, comprehensive quality-control systems, validated methods for ensuring adequate processing, and designing processes with margins of safety that account for the level of risk associated with use of these devices.14 As part of this process, the healthcare industry should support and encourage continued research and partnerships between endoscope, reprocessor and sterilizer manufacturers to elevate the standard of endoscope processing from high-level disinfection to sterilization.4
Current guidance from professional organizations recommends sterilization whenever possible for processing reusable flexible endoscopes that are manufacturer-validated for sterilization.4,5 Many endoscopy departments and facilities have successfully transitioned the processing of high-risk endoscopes to low-temperature sterilization.15 Through thoughtful planning and staff education, healthcare facilities can implement changes in endoscope processing practices and workflow with minimal disruption. Leaders can positively influence the success of these transitions by keeping their teams focused on the outcomes of preventing infection outbreaks and improving patient safety.
References
    Saleh N. Post-endoscopic infection rates are higher than ‘1 in a million’. MDLinx. Published July 12, 2018. https://www.mdlinx.com/article/post-endoscopic-infection-rates-are-higher-than-1-in-a-million/lfc-2029.
    Benowitz I, Moulton-Meissner HA, Epstein L, Arduino MJ. The Centers for Disease Control and Prevention Guidance on Flexible Gastrointestinal Endoscopes: Lessons Learned from Outbreaks, Infection Control. Gastrointest Endosc Clin N Am. 2020 Oct;30(4):723-733. doi: 10.1016/j.giec.2020.06.009. Epub 2020 Aug 1. PMID: 32891228; PMCID: PMC7962740.
    Ofstead, C. L., Buro, B. L., Hopkins, K. M., Eiland, J. E., Wetzler, H. P., & Lichtenstein, D. R. (2020). Duodenoscope-associated infection prevention: A call for evidence-based decision making. Endoscopy International Open, 08(12), E1769–E1781. https://doi.org/10.1055/a-1264-7173
    Association for the Advancement of Medical Instrumentation (AAMI). American National Standards Institute (ANSI). ANSI/AAMI ST91:2021. Flexible and semi-rigid endoscope processing in health care facilities. AAMI.
    Association of PeriOperative Registered Nurses. (2023). eGuidelines for Perioperative Practice: Flexible Endoscopes.
    Adler, D. G, Yu, A., & Barakat, M. T. (2024). Frontiers in endoscopy, Series #89 Disposable endoscopes: Current status and future directions. Practical Gastroenterology. https://practicalgastro.com/2024/03/19/disposable-endoscopes-current-status-and-future-directions/
    van der Ploeg, K., Vos, M. C., Erler, N. S., Bulkmans, A. J. C., Mason-Slingerland, B. C. G. C., Severin, J. A., & Bruno, M. J. (2024). Impact of duodenoscope reprocessing factors on duodenoscope contamination: a retrospective observational study. Journal of Hospital Infection, 154, 88–94. https://doi.org/10.1016/j.jhin.2024.09.018
    Centers for Disease Control (CDC) and Prevention. (2008;2024). Guideline for disinfection and sterilization in healthcare facilities. U.S Department of Health and Human Services. https://www.cdc.gov/infection-control/hcp/disinfection-and-sterilization/index.html
    Rutala, W.A., Weber D. J. (2023) Reprocessing semicritical items: An overview and an update on the shift from HLD to sterilization for endoscopes, p.98 American Journal of Infection Control https://doi.org/10.1016/j.ajic.2023.01.002
    Canadian Standards Association (CSA) Group, National Standard of Canada (2023). Canadian medical device reprocessing in all healthcare settings, Z314:23, 12.6.1, p.161
    The Joint Commission. (2025, January). Comprehensive Accreditation Manual for Nursing Care Centers ( CAMNCC) Update 2, 2025, Patient Safety Systems, number 4 CAMNURSINGCARECENTER_PS_Jan_2025.pdf, p.1
    Multidisciplinary and Multisociety Practice Guideline on Reprocessing Flexible Gastrointestinal Endoscopes and Endoscopic Accessories. (2020). Clinical Endoscopy, 53(3), 276–285. https://doi.org/10.5946/ce.2020.106
    Klacik, S.G., Transitioning from High-Level Disinfection to Sterilization for Semicritical Devices, AAMI/ARRAY, 2019, Transitioning from High-Level Disinfection to Sterilization for Semicritical Devices, https://array.aami.org/doi/epdf/10.2345/0899-8205-53.s2.23
    (2022). Infections Associated with Reprocessed Duodenoscopes. FDA. https://www.fda.gov/medical-devices/reprocessing-reusable-medical-devices/infections-associated-reprocessed-duodenoscopes
    Nadeau, K. (2024, August 27). Key Considerations for Transitioning Scopes from HLD to Sterilization. Hpnonline.com; Healthcare Purchasing News. https://www.hpnonline.com/sterile-processing/article/55129311/key-considerations-for-transitioning-scopes-from-hld-to-sterilization

### Breaking the Burnout Cycle
Burnout and a shortage in healthcare, particularly in nursing, have reached a critical point. Even before the pandemic, the nursing profession faced challenges such as an aging workforce and increasing demand for care. Today, the situation has escalated, with 42 out of 50 U.S. states projected to experience a critical nursing shortage by the year 2030. This shortfall makes it increasingly difficult to meet the patient-care standard of one nurse per four patients, leaving healthcare systems struggling to keep up.
Experts anticipated this crisis over a decade ago, citing the impending retirement of a significant portion of baby-boomer nurses. The global pandemic then pushed the already strained system to its near breaking point.
The impact of understaffing creates a vicious cycle. Fewer staffers means heavier workloads, leading to burnout and more resignations, which further exacerbates the problem. This results in higher patient loads, longer wait times, increased stress for healthcare workers, and a greater risk of errors—all contributing to poorer patient outcomes.
Having endured the strain of the pandemic and its impact on healthcare workers, the system now has an opportunity to change. By addressing the root causes of burnout and supporting nurses through better staffing and workplace improvements, we can break this cycle and ensure a stronger, more resilient healthcare system.
Leveraging Technology
Technology is transforming the way we train future nurses by enhancing practical learning and creating opportunities for students to navigate real-life ethical decisions. Nursing schools, such as the Arizona College of Nursing, now utilize advanced simulation labs that immerse students in realistic environments—from hospital rooms to home-care settings. These labs allow students to refine critical skills in scenarios that closely mimic real physiological responses.
Before entering clinical rotations, students gain hands-on experience in identifying heart and lung symptoms, assisting with childbirth, recognizing strokes and practicing other vital skills. They also lead their peers in active clinical decision-making, preparing them to handle complex situations with confidence.
In addition to improving training, technology can alleviate stress for healthcare workers by streamlining administrative tasks, scheduling and communication. Reducing these burdens helps create better outcomes for both healthcare teams and patients.
Flexibility and Accessibility in Nursing
There is a pressing need to expand opportunities for career changers and nontraditional students by offering flexible scheduling, especially for those balancing school with other responsibilities.
Working three consecutive 12-hour shifts—often stretching to 14 hours or more—is unsustainable and a direct path to burnout. Staff scheduling should prioritize manageable workloads to support long-term retention and well-being.
To meet the growing healthcare demands, the profession must be accessible to students from diverse backgrounds and life situations. Many students today juggle school, work and family obligations. By providing flexible options and resources to help them overcome potential barriers, we can support their success and build a stronger, more inclusive healthcare workforce.
Providing a Network of Support
Nursing is an incredibly challenging profession, both academically and in practice. Educators and clinical partners must work together to prepare nurses for the realities of the job, including how to handle loss, stress and tough decisions. Offering mentorship, individualized learning opportunities and mental health resources can significantly reduce burnout.
Partnerships between clinical organizations and educational institutions are vital. These collaborations help new nurses transition smoothly into the workforce, reducing “first-year burnout” and ensuring they are fully prepared to deliver quality care. Support roles across healthcare systems must also adapt to evolving needs, as they play a crucial role in sustaining a functional and healing environment.
By addressing these areas—technology, flexibility, and support—the healthcare industry can take meaningful steps toward breaking the cycle of burnout, addressing staffing shortages, and creating a sustainable future for nurses and their patients.

### AfterCare: Vacation on a Small Island
“Little islands are all large prisons; one cannot look at the sea without wishing for the wings of a swallow.” — Sir Richard Francis BurtonA small island?Well, the ‘bed’ I’ve been sleeping on in my living room during my first three weeks of recovery is scarcely a twin—it’s a chaise lounge on risers, dimensions 30 inches wide and 70 inches long, shared most nights with two frisky, two-year-old kits ‘of unusual size.’ However, it’s been an experience I wouldn’t trade for anything.Why is that? When I was told that the plan post-op (left knee replacement, late January 2025) was six weeks of home physical therapy three times weekly, I reframed it as an opportunity.“When life gives you lemons, sell them and buy a pineapple.” — Davin TurneyI don’t know about you, but after the COVID crisis waned, I had wondered what I might have chosen to accomplish if I had known going into the isolation just how long it would last. At least, I’d have done some ab work or yoga for increased flexibility (and who couldn’t benefit from some ab work?). Here I am, gifted with six weeks within my home, not allowed to descend my entry stairs until greenlighted by Carolyn, my amazeballs physical therapist.“Small islands of coherence in a sea of chaos have the capacity to shift the whole system to a higher order.” — Ilya Prigogine, Nobel Prize-winning chemistSo, I made a list. Those who know me snort at this—my method of coping with anything is list making, strategizing and planning—and I am quite satisfied when I achieve between 50-75 percent of my goals. I make lists on the backs of junk mail envelopes, 3 x 5 cards, my bullet journal. For this project, I broke out the “Big Paper.” What is this, you may ask? It’s a pad of 2 x 3-foot Post-It note paper that I use when facing a long project with many facets over time. Yes, the paper is similar in width to my cot.What are the highlighted plans for my six weeks on a small island? By the way, my small island includes the aforementioned cot, a bathroom with walk-in shower, shower chair and raised toilet seat, kitchen, living room with large-screen TV, and my desk and computer. Laundry and my expansive queen bed are just out of my reach upstairs. Hardly an average prison cell.“Life is a mind game. Decide what game you’re going to play with your mind.” —AnonymousFor mental stimulation, I am reading my local book club assignments (last week, the club met at my home, and the ladies brought the healthy party food), continuing my daily dose of Duolingo (over one year of Italian lessons), watching selected documentaries (“Best of” lists for both Netflix and Amazon) and reading nonfiction for 30 minutes daily.“You don’t get anything clean without getting something else dirty.” — Cecil BaxterI started a TDAD project; standing for “Two Drawers A Day” in which I select drawers that matter to me in no other order for clean out/straightening. These include drawers in my nightstand, desk, kitchen, TV stand, pantry, storage areas ... the only limit is that they are within reach of seated me. Go, me! I’m feeling so decluttered. I also cleared up some accounting issues requiring patience and my über-pleasant telephone voice for over a week, started organizing my taxes (as it would truly bite to still have those to do in March having been sequestered throughout February), and organizing my recipes (I have three bins of printed recipes that needed sorting and filing. I’m partway through; it’s not a fun task, but necessary).“Don’t forget to drink water and get some sun. You’re basically a houseplant with more complicated emotions.” — AnonymousI did well with twice-daily moisturizer (face soft as a baby’s bottom, with both moisturizer and being sequestered from the harsh weather of February), my home PT (twice a day), and making good food choices. I’ve enjoyed using my kitchen’s abundance of dried legumes. I also had the welcome support of friends, as they entertained me when invited for book club, Mexican Train dominoes and frozen margaritas, and twice-weekly lunches (I ordered, and they picked up). Not compliant with planned chair yoga, Pilates core work, and daily meditation. Ah, well.“We talked of mice, the cat and I, and of the importance of napping.” ― Catherine Gilbert MurdockIn addition to frequent visitors, I leaned on my two-year-old sibling kits, Finley and Evie. When not napping, we’ve done well with daily play with wands and laser lights, and with treat/ clicker training. We are all three failing at kit dental hygiene.“The monotony and solitude of a quiet life stimulates the creative mind.” — Albert EinsteinI’m enjoying plant care for my numerous houseplants (and the IKEA rolling cart makes an excellent functional watering and pruning walker), but haven’t had a hankering to do other creative outlets on my suggested list. Like crocheting scrub pads, doing Zentangle, or painting rocks. Meh—I guess I was thinking like a creaky lady when I made that Big Paper list. As a callback to the COVID days, I’ve embraced online shopping spending time and cash at ThredUp, a well-designed online clearing house for stylish thrifted clothing.So, what’s next?“Remember that life is an ADVENTURE, and cheer ‘Whee...’ all the way down the slippery razor-blade of life.”— Jonathan Lockwood HuieI’m halfway through my six-week confinement and am still of sound mind and heart. I will plan to up my game with that missing core and flexibility work, a focus on feline oral hygiene, and get the tax prep completed by the last week of my incarceration. Additionally, I’ve just rented the adult son of a friend (in between his archeology master’s degree and his first dig, with time to spare) to work on household projects I cannot yet accomplish.“Every island to a child is a treasure island.”— P. D. JamesAnd when I’m done? A brand-new knee, and an experience I wouldn’t have traded for anything. I have indeed treasured this experience in time.

### TechTalk: The Ultimate Litmus Test
The effectiveness of a sterilization process is contingent upon a successful preparation phase, the proper operation of equipment, and the expertise of the reprocessing technician. Currently, most flexible endoscopes are subjected to high-level disinfection (HLD), with only a limited number validated for sterilization, despite a growing number of infections and outbreaks reported by the Food and Drug Administration.
Earlier this year, the FDA announced it is investigating the source of 450 infections associated with patients who underwent procedures involving urological endoscopes. These cases, which occurred between January 2017 and February 2021, are documented in Medical Device Reports submitted to the FDA. According to the FDA, inadequate reprocessing of the scopes used in these procedures could cause infections.
In an April letter regarding these investigations, the agency recommended high-level disinfection or low-temperature sterilization to mitigate infection risks. These incidents and subsequent investigations have sparked a debate among experts about the most effective reprocessing method for these delicate instruments to ensure patient safety.
Keeping It Clean
Sterilizing flexible endoscopes is important. While most flexible endoscopes typically undergo high-level disinfection, sterilization remains a crucial part of their reprocessing, along with their accessories. However, a common misconception is that if items are placed in a sterilizer and the cycle is completed, those items are automatically considered sterile.
This is far from the truth.
In reality, the device cannot be deemed sterile if the steps leading up to sterilization are not meticulously performed. For sterilization to succeed, proper cleaning, testing, inspection, assembly, positioning, packaging and loading must be done correctly.
Cleaning an endoscope is recognized as the most vital step in its reprocessing. Inadequate cleaning can leave residual debris that obstructs effective disinfection, significantly increasing the risk of infection transmission to patients. This concern is amplified by the sensitive nature of the internal channels and the likelihood of significant bacterial contamination from bodily fluids encountered during procedures. Ultimately, the guiding principle remains: “You can’t disinfect what isn’t clean.”
Cleaning is imperative because any delay in the process allows organic material to stay on the endoscope, forming a biofilm. This biofilm effectively shields bacteria, making them far more challenging to eliminate. Strong disinfectants or sterilants often fail to penetrate through residual debris, leaving pathogens viable and posing a risk of transmission to other patients. Due to the critical infection risk, healthcare facilities are obligated to follow stringent guidelines for endoscope reprocessing to ensure the prevention of infection transmission.
According to Cori Ofstead, MSPH, founder and CEO of the medical research firm Ofstead & Associates, the sterilization process is “more rigorous than high-level disinfection and provides a much larger margin of safety.”
Sterilization offers much greater assurance of eliminating microbes and provides a substantial safety buffer against potential patient infections. This is due to the more thorough kill rate achieved during sterilization. Sterilization is often characterized by a significantly more significant “log reduction” than disinfection, typically reaching a higher log10 reduction of microbes. This underscores the critical importance of sterilization in ensuring patient safety in healthcare settings.
The Best Agent for the Job
There are a few methods for sterilizing endoscopes today: ethylene oxide (EtO), vaporized hydrogen peroxide (VH2O2), paracetic acid, and plasma. EO is not commonly used but still exists in some areas. EtO is a colorless, flammable gas used mainly as a sterilizing agent for medical equipment and certain food products like spices, as it can effectively kill bacteria even on materials that cannot be sterilized with heat; however, due to its potential to cause cancer with prolonged exposure, it is considered a hazardous air pollutant, and its use is strictly regulated by environmental agencies like the EPA.
Vaporized Hydrogen Peroxide
VH2O2 is a form of hydrogen peroxide that exists as a vapor. It is harnessed primarily for its antimicrobial properties in various sterile environments. This versatile agent decontaminates enclosed spaces such as hospital rooms, laboratory workstations and aircraft interiors, playing a critical role in infection control and bio-decontamination processes. One of the standout features of VH2O2 is its effectiveness in sterilizing heat-sensitive medical devices. Traditional sterilization methods, such as autoclaving, rely on high temperatures that could damage delicate instruments.
In contrast, vaporized hydrogen peroxide can effectively eliminate many pathogenic microorganisms, including bacteria, viruses, and fungi, without requiring elevated temperatures. This property makes it particularly valuable in hospitals and other healthcare settings where maintaining the integrity of medical instruments is crucial.
When exposed to air, VH2O2 breaks down into harmless byproducts: water and oxygen. This transformation underscores its reputation as an environmentally friendly disinfectant. Moreover, when vaporized, hydrogen peroxide molecules can penetrate various surfaces effectively. This penetrative ability enhances its capacity to kill microorganisms in hard-to-reach areas, making it an efficient choice for thorough disinfection.
Low-temperature sterilization is perfect for applications involving materials that are sensitive to heat. Certain plastics, electronic components, and other fragile materials that cannot withstand traditional sterilization techniques can be safely treated with vaporized hydrogen peroxide. Some endoscopes on the market today, such as bronchoscopes, cystoscopes and rhinolaryngoscopes, are validated for VH2O2 sterilization.
However, while VH2O2 is recognized for its antimicrobial efficacy and safety in many applications, it has some drawbacks. High concentrations of vaporized hydrogen peroxide can lead to potential skin irritation or respiratory discomfort if inhaled, emphasizing the need for adequate ventilation during application. Proper monitoring protocols are essential to maintain a safe working environment while using this agent. Additionally, VH2O2 can be corrosive to certain materials, limiting its use in specific contexts or requiring careful selection of compatible materials.
Overall, vaporized hydrogen peroxide is a powerful and effective solution for sterilization and decontamination. It combines high efficacy against various microbes with a relatively safe and environmentally benign profile.
Peracetic
Peracetic acid is a powerful liquid sterilant (LCS) utilized with a specialized liquid chemical sterilization system to disinfect heat-sensitive medical devices effectively. In this process, the device is fully immersed in the sterilant, ensuring thorough exposure to eliminate pathogens, and subsequently rinsed to eliminate residual sterilant.
During the rinsing phase, the water is meticulously treated to eradicate or neutralize harmful microorganisms, including bacteria, viruses, protozoa and fungi. This makes the system adept at processing various flexible endoscopes commonly used in multiple medical procedures.
Although this system is classified as a point-of-use sterilizer, it is essential to note that if the disinfected devices are not immediately used and are instead stored after the sterilization cycle, their status changes from sterile to high-level disinfection, which may not ensure complete safety against microbial contamination. The entire sterilization cycle is precisely timed at 30 minutes, utilizing a neutral pH use dilution specially formulated to protect delicate instruments from potential damage. Given the chemicals involved, personnel handling the sterilization must don appropriate personal protective equipment to ensure their safety and minimize exposure risks.
Gas Plasma
Plasma sterilization is an innovative and efficient process designed to eliminate microorganisms from surfaces using the unique properties of gas plasma. This method operates at low temperatures, making it exceptionally suitable for items that are sensitive to heat, such as delicate medical devices, advanced electronics and various agricultural products. The process begins by injecting hydrogen peroxide into a specially designed vacuum chamber. Inside this chamber, the hydrogen peroxide is vaporized, transforming into a gas that thoroughly permeates the enclosed space. Radio-frequency or microwave energy is then applied to create the plasma, causing the hydrogen peroxide gas to ionize and form a reactive plasma state. This plasma is rich in free radicals, which are highly energetic particles capable of damaging the cellular structure of microorganisms, disrupting their vital functions.
As the sterilization process unfolds, the plasma undergoes a transformation and ultimately breaks down into harmless by-products: water and oxygen molecules, both nontoxic and environmentally friendly.
One of the standout features of plasma sterilization is its effectiveness against various microorganisms, including resilient bacteria, stubborn fungi and harmful viruses. Moreover, this method can significantly reduce cycle times compared to traditional sterilization techniques, enhancing efficiency in settings that require rapid turnaround. Plasma sterilization proves invaluable for sanitizing medical instruments, especially those prone to corrosion. This allows for safe, reliable use in critical healthcare applications. Plasma sterilization is a cutting-edge solution for maintaining hygiene and safety in numerous sensitive environments.
Mission Critical
The growing momentum to adopt sterilization protocols for endoscopes is primarily driven by the substantial risk posed by patient-to-patient transmission of infections linked to inadequately disinfected instruments. This concern is particularly acute for endoscopes interacting with mucosal surfaces, such as gastrointestinal scopes that are directly exposed to internal bodily environments. Sterilization techniques provide a markedly enhanced level of decontamination, eliminating nearly all types of microorganisms, including highly resistant spores that can survive standard disinfection processes. These spores can potentially initiate severe infection outbreaks that can have dire consequences for patient health if not addressed through rigorous decontamination practices.
Moreover, the intricate and often sophisticated design of endoscopes— including their narrow lumens, complex moving parts, and multiple channels—presents significant challenges for thorough cleaning and adequate disinfection. This complexity increases the likelihood of residual contamination and emphasizes the necessity for reliable sterilization methods to ensure patient safety and prevent the risk of infection. The shift toward a sterilization approach is essential in addressing these critical concerns and protecting patient well-being.
High-level disinfection (HLD) is widely recognized as the gold standard for reprocessing semi-critical flexible endoscopes. This classification stems from the Spaulding Classification system, which categorizes medical devices based on their risk of infection; according to this system, most flexible endoscopes are designated as semi-critical devices. During diagnostic and therapeutic procedures, these devices make close contact with intact mucous membranes. Still, they typically do not penetrate sterile tissues within the human body, and this factor influences the appropriate level of disinfection required.
Disinfection is a critical process defined as “the method to inactivate viable microorganisms to a level that is considered safe for a specific purpose” (ISO 15883-4:2018). HLD is particularly important in this context, as it ensures that the endoscopes are sufficiently disinfected to prevent infection while maintaining their functionality and integrity.
Despite ongoing discussions surrounding sterilization techniques, there is a lack of substantial evidence demonstrating that sterilization yields significantly better clinical outcomes compared to high-level disinfection. As a result, HLD continues to be the preferred and most widely accepted method for processing flexible endoscopes, balancing efficacy in infection control with practical considerations of device handling and patient safety.
In policy, the Centers for Disease Control and Prevention aligns with the Food and Drug Administration: if a medical device can be sterilized, it should be sterilized. The FDA actively encourages manufacturers to sterilize any device, as proper sterilization is crucial for preventing patient infections and is considered a standard practice for medical devices that come into contact with sterile body tissues or fluids. If the margin of safety is higher with sterilization, the facility should use the method with the highest level of validated reprocessing methods.
The ultimate litmus test is what is best for the patient.

### Reaching New Heights
At Summit Medical Group Ambulatory Surgery Center in Berkeley Heights, New Jersey, one factor that makes the team excellent is “the working relationship and the trust that the physicians and the staff have for one another,” said Kimberly Bujnowski, director of nursing.
The Summit facility is a multi-specialty center with six rooms, three of which are dedicated to endoscopy procedures. “We perform colonoscopies, upper endoscopies and endoscopic ultrasounds,” Bujnowski said. The staff includes seven gastroenterology technicians and eight RNs.
As a part of VillageMD, Summit Health is dedicated to envisioning a world where people “live longer, healthier lives in stronger communities.” The group’s focus is advancing healthcare by providing high-quality, compassionate care that keeps patients’ needs and best interests firmly front and center. “Our team is patient-focused, and the physicians, nurses and technicians work cohesively to ensure the best patient care possible,” Bujnowski said.
As with most top-notch endoscopy centers, excellence doesn’t just happen. At Summit Medical, it starts with education— specifically, the Certified Endoscope Reprocessor certification available  through  the  Healthcare  Sterile  Processing Association. “The department made the decision to require CER certification for our employees in 2024,” Bujnowski said. “Despite the challenging period, the vast majority have obtained certification as required. By doing this, the staff will be kept up to date on evolving regulatory standards.”
Before an applicant can even be considered for testing, they must first complete three months of hands-on work experience. The hours can be completed on a professional or volunteer basis, but they must include reprocessing endoscopes in a medical center, hospital, surgery center, or independent endoscope center, according to the HSPA. They wrote, “firsthand experience is essential to supplement an individual’s understanding of the necessary knowledge and concepts of reprocessing, and to illustrate their practical use. This experience must include the pre-cleaning, testing, decontaminating, inspecting, disinfecting and/or sterilizing, transporting, and storing of endoscopes.”
The subsequent exam was developed “to measure the un- derstanding of endoscope care and handling and infection prevention,” according to the HSPA. Study materials recom- mended include:
 	HSPA’s Endoscope Reprocessing Manual (2nd ed.)
 	ANSI/AAMI ST91 (2022 ed.)
 	CDC’s Essential Elements of a Reprocessing Program for Flexible Endoscopes (2017 ed.)
 	Articles by the Society of Gastroenterology Nurses and Associates (SGNA): Standard of Infection Prevention in the Gastroenterology Setting (2019), and Standards for Infection Prevention in Reprocessing Flexible Gastrointestinal Endoscopes (2018)
 	SGNA’s Guidelines for Use of High-Level Disinfectants & Sterilants in the Gastroenterology Setting (2017 ed.)
Certification doesn’t stop there. Certificate holders must recertify every year by taking continuing education.
And the dedication pays off. Roger Klein, M.D., observed, “The team is so proficient that they are able to anticipate patient and physician needs which helps make the day run smoothly and efficiently.”
The team works hard, but they also take time to recharge by hosting potluck lunches. According to Bujowski, the staff has an off-site dinner on a quarterly basis, and they end the year “with a huge holiday party as we celebrate the conclusion of a fantastic year and the start of an even better one. The staff really enjoys the events and contribute by choosing themes, location and—most importantly—food.”
Hazar Michael, M.D., said, “What makes the team special is that the staff is diligent about their work, and they take pride in and enjoy their work.”

### Water Works
Any medical professional who works at a gastroenterology office knows the importance of a good colonoscopy prep for patients. A poor prep equals poor pictures. Done deal. It’s that simple. But also simple: Everyone hates the standard prep process. Our cover story this month focuses on colon hydrotherapy and whether it makes for a good prep alternative.
In the precursor to this publication, EndoNurse Magazine, we long ago did a cover story that asked whether colon hydrotherapy should be more widely used as a prep. I was intrigued by the article and the very topic of hydrotherapy, because as we all know, the compliance rating for standard colonoscopy prep is too low. I was open to potential solutions. Colon hydrotherapy sounded like a decent alternative, but the method was far from mainstream. That was about 15 years ago, and not a lot has changed in this regard.
When I was searching recently for a gastroenterologist I tried to find one who would allow hydrotherapy as a prep, since I have all the same fears of a traditional prep that most people have. My tract is already troubled enough, thank you. I don’t want to throw violent diarrhea and potential vomiting into the mix. I live in a large metropolitan area (okay, it’s urban sprawl: Phoenix, Arizona) with a huge number of gastroenterology practices and yet I couldn’t find any that accept hydrotherapy as a prep (and that accept my insurance).
Could I have tried harder? Probably. But it’s still safe to say that the average gastroen- terologist wants the standard prep, the whole prep, and nothing but the prep. That was certainly true for my gastroenterologist. Our conversation on the topic went as follows:
Me: Do you have an opinion on colon hydrotherapy as a prep? Her: Not happening. Don’t ask.
Me: So it’s not an option?
Her: Never. Next question. But not about hydrotherapy.
Not the best conversation I’ve had! She ended up retiring a month later, anyway, and my insurance won’t cover the procedure until July, so I’m waiting. I’d still like to be able to try the alternative, or at least find a gastroenterologist who will discuss it.
Do you have any opinion on hydrotherapy as a prep alternative? If so, I’d love to hear it! Please email me at Michelle.Beaver@endopromag.com. For the cover story, “The Ups and Downs of Hydrotherapy: An Alternative Colonoscopy Prep,” visit p. 16.

### Robotics in Pulmonary Endoscopy
Traditionally, endoscopy departments focus on procedures of the gastrointestinal system. When I joined this field at the end of 2023, that focus was evident in the expertise and training of my team. Many of my colleagues are experienced endoscopy professionals with strong backgrounds in gastrointestinal procedures.
In recent years, however, interventional pulmonary services grew, and a few team members learned these procedures, adapting as new technologies emerged. In early 2024, a switch in robotics providers impacted some of these procedures, and we decided to transition them from the operating room to an endoscopy suite.
As a newly appointed leader to the department, my motivation to focus on growing pulmonary procedures was driven by the combination of both the lure of untapped potential and the support of an exceptional team. With my background in cardiac and pulmonary nursing, I was naturally drawn to this area of care.
Beyond personal interest, I saw the hidden promise both in the geographic area and in the organization. Southern New Jersey, despite its proximity to Philadelphia and Manhattan, is densely populated enough to warrant its own local, expanded healthcare services. Our location is near several casinos (a known source of respiratory exposures) which further highlighted the need for specialized, accessible pulmonary care.
Our endoscopy team is engaged, intelligent and motivated to provide excellent care. The providers within interventional pulmonology possess all those qualities, along with a willingness to be flexible, teach and grow with the team.
Another key factor in success is that the program had executive support and aligned with organizational strategic goals. I embraced my role as both an advocate for the program’s growth and a facilitator of its operational success.
Assembling the Team
Knowing how few team members were specialized in robotic pulmonary care, we addressed this gap by focusing the initial deployment on team members who were engaged with the previous robotic implementation. The recipe to develop this pulmonary care team was a simple one, and we already had all the ingredients. With support from our partners at Intuitive Surgical, we facilitated on-site training in Atlanta.
We continue to fine-tune our processes, focus on cross-training more team members, and find ways to streamline turnover methods— which ultimately have increased procedural capacity. The more procedures we can do, the more diagnoses we reach—leading to prompt treatment, faster responses and better outcomes for our patients and communities.
This has been both deeply impactful and inspiring work, but translating progress into the day-to-day operations can be daunting. One significant challenge was ensuring this growth of pulmonary procedures did not feel like a burden for the team, but instead an opportunity for improved patient care, personal impact and professional growth.
Staffing presented another layer of complexity to consider. Balancing a steady volume of patients along with organizational and unit-ba- sed changes impacting team morale required thoughtful navigation.
Additionally, the operational shuffle of pulling team members offline for training in an intricate new process required strategic planning to maintain team cohesion and patient coverage.
Overcoming Obstacles
Our department, together with the operating room, previously utilized a different robotic system for navigational bronchoscopies. Although this was effective, it posed significant operational challenges. It required extensive setup and takedown, necessitating patient transport and at least an hour of preparation time.
Previously, all of these cases had occurred in the operating room, demanding the movement of equipment—such as protective lead aprons, specimen containers, medications, etc.—as well as staff across multiple areas of the hospital. This logistical burden decreased the amount of time our team could spend with direct patient care.
To address these inefficiencies, we held many discussions about how to more seamlessly integrate the program into the endoscopy unit. Clear communication was a priority, so I spoke with each team member involved to be sure they understood the rationale behind these changes. We talked through what was needed in an effective handoff.
I gathered their input on what an ideal implementation would look like. With their feedback as a guide, I worked to remove obstacles and secure whatever resources they needed to succeed. Strong representative presence helped the team in realtime. When I encountered challenges beyond my expertise, I sought advice from colleagues. I asked a lot of questions.
We collaborated closely with radiology, IT, IT security, and Intuitive’s team to ensure seamless integration with the PACS system. (A PACS, or picture archiving and communication system, stores medical images and reports).
We collaborated with sterile processing. Additionally, we engaged with colleagues from other disciplines to enhance the patient ex- perience, ensuring it was efficient and patient-centered. The dedication and investment of the pulmonary team to their patients and exceptional care delivery was evident throughout.
Milestones and Achievements
In just four months, our team achieved a remarkable milestone, completing over 50 cases and increasing our daily procedural volume from two navigational bronchoscopies per day to five. This was a testament to the team’s collective efforts and dedication.
We celebrated this together, with our providers emphasizing the difference prompt, accurate diagnoses can make in the life of a patient. In one instance, the pulmonary team was able to sample from a lymph node that would have previously required a sternotomy to reach. This was a significant clinical milestone for the endoscopy team to participate in and witness.
We learned to adapt as we saw issues arise. We adapted the scheduling models to ensure patient care coverage was more than adequate.
The outcome? Proficiency grew.
In five months, the percentage of the endoscopy nurses proficient in these cases grew by 250% and technicians showed a 100% growth, doubling their team’s proficiency! Team members were engaged and satisfied. To ensure efficiency and reduce fatigue, we implemented a buddy system for cases and room breakdown. This ensured refreshed perspectives and maintained high standards of care throughout the day.
Lessons Learned
The most important lesson learned throughout this process was that partnership and collaboration are tantamount to success.
Endoscopy teams already handle a complex workflow, managing high-level disinfection, and partnering with procurement for inventory management. The team routinely performs POUT (Peri-Operative chemotherapy versus surveillance in upper-tract urothelial cancer), manual cleaning, automated disinfection, forced air drying, protein-testing and storage management. In this case, a key partnership with the hospitals’ sterile processing department was essential for parts that cannot be immersed and needed sterilization.
The new robotic system introduced new challenges, such as parts with defined case-lives. This required reconfiguration of how the inventory for each of these parts were managed. The team devised a couple strategies to manage stock electronically, pivoting when necessary and partnering with our buyers.
Delicate Nature
Given the delicate nature of robotic parts—with sensors and small components—case setup and room turnover became more intricate. These and other processing challenges were met with training, repetition, troubleshooting support, more training, and ongoing collaboration to ensure the team was equipped to adapt effectively.
Procedural space constraints added another layer of complexity.
Geographic changes to the procedural room and on the unit are ongoing and prove critical to optimize turnover time and workflow efficiency. Even small adjustments, such as the direction a door swings, can significantly impact procedural flow. By working with facilities and construction management we explored new layouts for the equipment and procedural personnel. Regular check-ins with the team allowed their feedback to be incorporated in decisions about space utilization, workflow and room layout.
We made changes gradually to facilitate adaptation and align with budget constraints. We empowered the team members by involving them in decisions. This approach fostered a sense of shared ownership.
This implementation taught me a few things as well, such as that I work with some incredibly talented people. I also learned that over- communication is unlikely (but forgivable) when undertaking a process change.
Questions are essential.
My main summary after this process is that I’m so proud of my team and I’m inspired by their successes. They are truly phenomenal.

### Digestive Enzymes for FODMAPs
Research has shown that a diet that is low in fermentable oligo-, di-, monosaccharides and polyols (FODMAPs) helps manage abdominal pain, bloating, and other digestive symptoms in 70-75% of patients with irritable bowel syndrome (IBS). However, the low-FODMAP enzyme supplements can be challenging and access to registered dietitians (RDs) and other healthcare providers trained in the low-FODMAP diet is limited.
I would know.
I’m an RD with a specialty in gastrointestinal (GI) nutrition, and I provide education and resources on FODMAP intolerances to gastroenterologists (GIs), nurses, RDs and other providers.
I’m also part of the team at Kiwi Biosciences, the biotechnology company behind FODZYME. FODZYME is a novel digestive enzyme blend specifically designed to break down the most common FODMAP triggers: fructan, galacto-oligosaccharides (galactans/GOS) and lactose.
FODZYME’s Founding Story
FODZYME was developed based on personal experience. When Anjie, our cofounder and CEO, was forced to restrict herself from enjoying her favorite foods on an effective (yet frustrating) low-FODMAP enzyme supplements, she rallied a group of world-class experts in research, medicine and nutrition to create a scientific approach to break down FODMAPs before they cause digestive distress. This novel approach to managing FODMAP intolerance led to the creation of FODZYME and enabled her to put foods like garlic, onion, wheat, chickpeas and more back in her life.
Some patients find the low-FODMAP diet too hard to follow. They may experience cravings, increased food stress and anxiety, development of disordered eating behaviors, nutrient deficiencies and troubling alterations in gut microbiota.
Since day one, our mission with FODZYME has been to provide digestive relief and improve the quality of life for patients with FODMAP digestive enzymes issues. We’ve very much valued our partnerships with professional gastroenterology organizations, research institutions, hospitals, clinics and our world-class advisors, including Dr. Bill Chey, chief of the division of gastroenterology and hepatology at Michigan Medicine. Digestive enzymes are increasingly recognized as a highly effective tool for those with FODMAP intolerances to ensure nutritional adequacy, dietary flexibility, symptom relief and quality of life.
The Power of Digestive Enzymes
Broadly speaking, enzymes are specialized proteins (chains of amino acids) folded in particular ways. FODMAP-targeting digestive enzymes are designed to break down FODMAPs in foods before they can trigger symptoms.
There’s a mature body of research supporting the efficacy of digestive enzymes for FODMAPs intolerance, and their long-term safety is well-recognized. However, I’ve found many healthcare providers rarely utilize this science with patients until they learn about FODZYME.
In fact, guidelines published in the Journal of Neurogastroenterology and Motility on how to implement the low-FODMAP diet into gastroenterological and nutrition practice recommend the use of digestive enzymes for symptom management and to allow for more dietary flexibility during the third personalization phase of the low-FODMAP diet.
Monash University, the leading research institution on FODMAPs and the low-FODMAP diet, also recommends use of digestive enzymes to enable a less restrictive diet long-term while managing symptoms. For example, digestive enzymes allow for increased intake of tofu, peas, legumes, nuts, soy, whole grains, dairy and many other nutrient-rich, high-fiber foods to avoid nutritional deficiencies and their consequences.
FODMAP Digestive enzymes are also recommended prior to or in lieu of a traditional low-FODMAP diet in patients with bloating, gas and other lower-GI symptoms who are not good candidates for the three-phased diet. Those who already identify high-FODMAP foods as triggers (such as garlic, onion, wheat and beans) can benefit from digestive enzymes right away. Patients at increased risk for disordered eating or with other contraindications for a restrictive diet (e.g., children and the elderly) can use enzymes alongside their existing diet.
A Scientific Approach
FODZYME represents two layers of innovation: a highly efficacious powder format and a proprietary Fructan hydrolase supplement. Let’s dive into both.
The importance of a powder format
It’s crucial to maximize FODMAP-enzyme homogenization as soon as a meal is consumed, which is why FODZYME is a powder. FODMAP digestive enzymes begin work as soon as they come into contact with FODMAPs and are most effective when they can freely homogenize with food. A powder facilitates greater contact between the enzymes and their target FODMAPs at the post-prandial gastric pH most favorable to FODMAP breakdown, which leads to greater efficacy than a pill or capsule.
In fact, Fodmap digestive enzymes in capsules or pills are a less efficacious method for delivering carbohydrate-targeting enzymes, as they isolate enzymes from their intended target and may be deactivated in the stomach before coming into contact with FODMAPs. (Note: this is not the case for prescription enzymes; these enzymes are generally encapsulated to delay release until arrival in the small intestine.)
FODZYME’s Novel Fructan Hydrolase Supplement
FODZYME is a blend of natural enzymes featuring fructan hydrolase, lactase and alpha-galactosidase. FODZYME’s fructan hydrolase supplement adds to the scientific and clinical field with its novel ability to break down the broad spectrum of fructans, including levan, inulin and fructooligosaccharides, which each vary in their chain length and linkages.
Fructans are widely recognized as the most common FODMAP trigger in IBS.
Furthermore, fructans and galactans/GOS provide particular benefits for digestive health by supporting short-chain fatty acid production (SCFA). These fibers are also in many high FODMAP foods that patients may have trouble tolerating. We’ve conducted extensive peer-reviewed research, published in the journal Gastro Hep Advances, to confirm that FODZYME administration with prebiotic fiber reduces but does not deplete SCFA production, suggesting that use of digestive enzymes with prebiotic-rich foods is favorable to overall colonic health than avoiding FODMAPs altogether.
In other words, with digestive enzymes, patients can more readily follow a high-fiber diet and benefit from fiber’s protective role against many gastrointestinal diseases, such as colon cancer.
Ongoing Research
Our team and research partners are regulars at the top nutrition and GI conferences, where we frequently exhibit and present. In 2022, we presented our findings at Digestive Disease Week (DDW) on FODZYME’s in-vitro efficacy.
We recently presented three abstracts on our clinical work at conferences including the Food & Nutrition Conference & Expo (FNCE), the American College of Gastroenterology (ACG) and North American Society for Pediatric Gastroenterology and Nutrition (NASPGHAN). Findings from these studies showed that after four weeks of FODZYME use, patients reported significantly less bloating, diarrhea, constipation and abdominal pain. While I cannot reveal too much here, we anticipate having additional publications on our clinical research to share in 2025.
Furthermore, our R&D on additional ways to develop products that support those with digestive issues continues. In our pipeline are novel approaches to tackle additional FODMAPs groups, like polyols such as mannitol and sorbitol.
Supporting Providers
Standard training for healthcare providers rarely covers in any depth how to integrate digestive enzymes into patient care. The educational programming I run aims to change that.
Our resources for healthcare providers include training on how to manage FODMAP intolerances while minimizing the impact of dietary restriction. We offer dozens of free trainings and materials for the clinicians, such as:
 	Webinars: Presented by expert GI clinicians, our free continuing-education webinars cover a wide-range of GI nutrition topics.
 	Educational handouts: Our free handouts for patients provide accessible, practical education on FODMAPs and how to effectively use digestive enzymes. The library also includes time-saving resources for providers to reference in their practice.
 	Clinic trainings: As an RD with deep expertise in Fodmap enzyme supplements, I often present on clinical application of enzymes and how to integrate them into the patient-care process.
 	1:1 Calls: Providers come to me with specific questions on complex cases, counseling approaches and our research, and I welcome the opportunity to share my knowledge with them.
It’s a privilege to support the diverse community of healthcare providers in our network. All these resources are available on demand on our website, fodzyme.com/partners.
Beyond background on FODMAPs, the benefits and potential cons of a low-FODMAP diet and the science of Fodmap digestive enzymes, points I emphasize are:
How to identify FODMAP intolerances?
FODMAPs tend to cause trouble 4-8 hours after a meal, which is when they generally reach the colon and trigger gas, bloating, diarrhea, constipation and abdominal pain. This can be a very helpful clue to watch for when helping patients get to the root of what may be driving symptoms. This also means that when using FODMAP-targeting enzymes, patients should expect to see a benefit roughly 4-8 hours after a high-FODMAP meal.
The pathogenesis of FODMAP intolerance
Except for lactase, the body does not produce enzymes for FODMAPs. Rather, FODMAP intolerances arise from alterations in the gut microbiota (dysbiosis), increased sensitivity to digestive processes (visceral hypersensitivity), their osmotic effect, and other miscommunications between the gut-brain-axis, although research remains ongoing.
Contraindications for the low-FODMAP diet
Restrictive diets must be implemented with extreme sensitivity in many groups, such as children, the elderly, pregnant women and other populations with additional energy and nutrient needs or challenges meeting them. Patients with low interest or ability to implement a low FODMAP enzyme supplements are also less likely to find symptom relief if they do try to follow one. These patients are better suited to a simplified FODMAP approach or alternative interventions.
Safety profile of digestive enzymes
Over-the-counter digestive enzymes for Fodmaps work on food (not the body). The enzymes will be metabolized like any other dietary protein if they do not break down in contact with FODMAPs, and their byproducts are excreted. They can be safely used as frequently as, and for as long as, FODMAP intolerances persist.
FODMAP Freedom
I’m passionate about educating on how FODMAP digestive enzymes provide benefits beyond symptomatic relief by enabling a more nutrient- dense, diverse diet. The many providers using FODZYME with their patients support us in our mission, as well. The most rewarding moments are when I hear success stories about how their patients are enjoying the foods they love without worry or pain.
“The best compliment I get from my patients is when they finally have freedom to eat what they love. FODZYME is so small [and] easy to use and now my patients can go out to their favorite restaurants. My patients have been enjoying high-fiber meals that are painless and make them feel good.”
— Dr. Kumkum Patel, M.D., board-certified gastroenterologist specializing in IBS
Dietary freedom also means patients can enjoy the integral cultural and social role food plays. From feeling free to join a communal family meal, to having the confidence to enjoy a catered meal at a friend’s wedding, patients who have been reluctant to expand their diet due to food fears or anxiety gain invaluable psychological benefits from digestive enzymes for Fodmaps.
“This has been life-changing. I’m able to dine out without worry. I no longer have excessive bloat after those meals.”
— Jennifer, FODZYME user of three years
Conclusion
For those with IBS, digestive enzymes allow for a tailored, nutritionally robust diet. Dietary flexibility and inclusion of delicious, high- FODMAP foods is possible with digestive enzymes for Fodmaps, even among the most FODMAP sensitive.
Our commitment at FODZYME is to educate healthcare providers on dietary and non-dietary lifestyle strategies to manage digestive symptoms. We all know IBS is a chronic condition that requires lifelong management. This makes it especially vital that providers can ensure their patients achieve adequate nutritional intake and can enjoy the many psychosocial pleasures of food with a plan that is sustainable on the long-term.
 
Foods FODZYME Helps Patients Tolerate:

### Hot Tips for IBS Taco Lovers
Many patients who are considering the Low-FODMAP Diet have concerns that they may be embarking on a bland-food regimen to obtain symptom relief, and that spicy foods such as chiles (chile peppers) will trigger symptom flare-ups. While many types of chiles have a low-FODMAP serving size, they have been found to contain the compound capsaicin, a natural compound that gives chiles their spicy quality.
To clarify, capsaicin is not a FODMAP. Individual tolerance levels for capsaicin vary and should be taken into consideration when preparing meals with chiles. (Source: Monash University Department of Gastroenterology).
“Many studies have shown that spicy food is associated with IBS symptoms in some people, and potentially more so in women with IBS,” said Kate Scarlata, MPH, RDN, and New York Times–bestselling author specializing in gut health and nutrition. “Capsaicin, found in hot peppers, may be the primary culprit. The science is a bit mixed in this area; however, it appears that capsaicin can increase GI transit and contribute to IBS-associated pain.
“Interestingly, capsaicin-induced pain appears to occur more commonly in individuals who don’t eat it often,” she continued. “It’s possible that regularly eating spicy foods actually desensitizes receptors in the gut associated with IBS pain. As with most food-related issues in IBS, it is not ‘one size fits all.’
People living with IBS should listen to their body and adjust diet triggers as needed. GI dietitians are best suited to help guide patients in detecting diet triggers for IBS symptoms. The least-restrictive diet to help manage symptoms is the goal to allow and foster a healthy relationship with food.”
The diet does not mean no FODMAPs. Instead, it’s a food plan based on serving sizes per meal in which foods that have tested to contain low levels of FODMAPs are encouraged for patients to consume, particularly during the beginning phase of the plan. High-FODMAP foods such as wheat-containing products and some chile peppers also have lesser, low-FODMAP portions. (Source: Department Of Gastroenterology Monash University, Online Patient Course).
Food swaps are also implemented. For example, white bulbs of onion have tested to be high-FODMAP and can be substituted with low-FODMAP green parts of scallions, chives and green parts of leeks.
Phase 1—Elimination
During this phase, patients consume low-FODMAP portions of foods. Jalapeño peppers were tested by Monash University, which maintains one of the largest FODMAP-tested food databases in the world.
Researchers found that fresh, raw jalapeño peppers are high-FODMAP at one medium-sized pepper per meal; however, one tiny jalapeño is considered to have a low-FODMAP rating and is compliant in the beginning elimination phase of the diet.
Phase 2—Reintroduction
Once the patient’s symptoms are under control, they methodically reintroduce moderate-FODMAP levels of foods. These are called food challenges, with three-day breaks between challenges. Patients test their tolerance to higher FODMAP consumption by eating low-FODMAP foods while introducing each subgroup (fructan, fructose, GOS, lactose, sorbitol, mannitol) separately, at moderate FODMAP levels to determine which trigger symptom flare-ups and those that do not. Patients can track their symptoms through a food journal to ensure the process is completed successfully.
Jalapeños contain fructose and have a moderate-FODMAP rating at one small pepper (slightly larger than tiny) per sitting. If symptoms are not triggered at this first serve size, patients may proceed to trial a higher-FODMAP serving size of one medium-sized jalapeño. If the challenge results in symptoms, patients then stop and try again later, in smaller amounts.
Phase 3—Personal Maintenance
While adding small amounts of trigger foods, patients identify their personal tolerances and develop a long-term, less restrictive dietary approach.
With regard to chiles, patients may choose to trial individual tolerance of serranos, cayenne powder, chipotle powder, and other spicy foods as they establish their personal balance.
Serrano chiles, cayenne powder and chipotle powder have low-FODMAP portion sizes. Fresh poblano peppers, fresh mild green chiles (including Hatch, Colorado Green, Anaheim, and Chiles Verde Del Norte) and canned mild plain green chiles have tested to contain low-FODMAP levels. (Source: Depart- ment Of Gastroenterology Monash University Smartphone App Database).
The Low-FODMAP Diet is not a lifetime food regimen. Millions of people following the diet find that in the reintroduction and personal maintenance phases they can tolerate varying portions of high-FOD- MAP foods and previous triggers. Personal sensitivities can change over time, opening countless possibilities in enjoying spicy, robust dishes such as fajitas, spicy tofu bowls and jalapeño poppers while maintaining calm digestion.
It is important for patients to be medically diagnosed with IBS by their gastroenterologist and work with a registered dietitian and healthcare professional when starting the Low-FODMAP Diet to tailor the plan to their particular sensitivities.

### Early Cancer Diagnoses Are on the Rise
The landscape of cancer diagnosis is shifting, with an alarming increase in early-onset cases among adults under 50. Traditionally considered diseases of aging, colorectal, breast, pancreatic and other malignancies are now being detected in younger individuals at rates that have caught the attention of epidemiologists and clinicians alike. While advances in screening technology play a role, they do not fully account for the rise, suggesting that changes in lifestyle, environment, and other external factors are at play.
The Epidemiology of Early-Onset Cancer
Colorectal cancer, in particular, exemplifies this worrying trend. Once considered a disease of older adults, cases among those in their 30s and 40s have surged over the past two decades. The American Cancer Society now recommends colorectal cancer screening to begin at age 45 instead of 50, an acknowledgment of the shifting epidemiology. Breast cancer diagnoses in younger women are also increasing, with a particular rise in more aggressive subtypes that are harder to treat. Similarly, rates of pancreatic and gastric cancers are climbing among younger individuals, despite overall declining trends in older populations.
Several factors likely contribute to this phenomenon. Rising obesity rates, sedentary lifestyles, and dietary shifts toward ultra-processed foods have been linked to chronic inflammation and metabolic dysfunction, both of which create a fertile environment for carcinogenesis. The gut microbiome, which plays a critical role in immune regulation and inflammation, may also be influenced by modern dietary and lifestyle patterns, potentially contributing to increased risk. Additionally, environmental exposures—ranging from endocrine-disrupting chemicals found in plastics to air pollution and occupational carcinogens—are under investigation as possible contributors to early-onset cancers.
Modifiable Risk Factors
The role of lifestyle choices in modulating cancer risk is well established, but recent evidence suggests that the impact of diet, exercise and environmental exposures may be particularly pronounced in younger individuals. The widespread consumption of diets high in refined carbohydrates, added sugars and processed meats has been associated with increased risks of colorectal and other gastrointestinal cancers. These dietary patterns promote systemic inflammation, insulin resistance and dysbiosis of the gut microbiome, all of which can contribute to tumor development.
Obesity, a growing public health crisis, is a well-documented risk factor for multiple cancers, including those of the breast, pancreas and liver. Excess adiposity contributes to a pro-inflammatory state and alters hormone levels, creating conditions that may promote tumor initiation and progression. Compounding these risks, sedentary behavior has become increasingly prevalent, particularly among young adults engaged in screen-based occupations and leisure activities. Physical inactivity is linked to decreased insulin sensitivity, increased inflammation and lower immune surveillance, all of which may contribute to carcinogenesis.
Beyond behavioral factors, the role of environmental exposures cannot be overlooked. Endocrine-disrupting chemicals such as bisphenol A (BPA), phthalates, and perfluoroalkyl substances (PFAS) are ubiquitous in consumer products and have been linked to hormone-driven cancers.
Air pollution, particularly fine particulate matter (PM2.5), has been implicated in increased risks of lung and other cancers, even in nonsmokers. Additionally, occupational exposures to industrial solvents, pesticides and shift-work-associated circadian disruption may further contribute to the rising incidence of cancer in younger populations.
Looking Ahead
As these epidemiological trends become clearer, researchers and public health experts are focusing on how best to refine screening strategies, identify high-risk groups and shape prevention efforts. While more studies are needed to fully tease apart the impact of genetics, lifestyle and environmental triggers, there is already substantial evidence supporting measures like improved nutrition, regular physical activity and reduced exposure to known carcinogens.
With early-onset cancer diagnoses on the rise, staying informed on these epidemiological trends is not only essential for clinical practice but also for contributing to broader public health efforts aimed at reversing these concerning patterns. The future of cancer prevention and early detection depends on proactive engagement from all corners of the medical community, with a focus on understanding and mitigating risk factors that drive these alarming trends.

### AfterCare: Under The Knife
Life is often like that, the best balancing on a knife edge, with the worst. ~ Laurell K. Hamilton
Eleven years.
That is how long my astoundingly patient orthopedic surgeon has cautiously suggested that I might enjoy a knee replacement... or two.
However, like most in medicine, I love medical care, so long as it is not directed at me. Avidly I had been following the research into plasma, platelet and/or stem cell injections into knee capsule to grow new articular cartilage in osteoarthritic joints—it seemed a great fad, one all the cool kids indulged in. However, on a telephone consultation with a blue-ribbon institution doing the research (rather than the freestanding clinics happy to take your platelets or butt fat and inject it in various locales without scientific oversight) the researchers acknowledged that the data was that cartilage could grow, just not in a well-organized or durable fashion. By the way, did you know that it is fairly unregulated to have someone take your own tissue and inject it into yourself? Truth.1
This fall, while prepping for a West Virginia hiking trip with friends (that preparation included steroid injections in both knees so that I could keep up) I threw in the metaphorical towel. The cartilage regrowth advocates had moved on to investigate a new technique—that of building a scaffold of material similar to resorbable suture material, inserting this pad into the knee space, and then trying to get cartilage to grow there with exercise-stimulated piezoelectric charges before the scaffolding dissolved. In rabbits.2
Yeah. Not gonna happen in humans anytime soon.
Time to move on so I can get a move on.
A wise doctor does not mutter incantations over a sore that needs the knife. ~ Sophocles
I had gone down swinging. Boswellia, turmeric, strawberries were all researched. Stretching, resistance exercise, Pilates, yoga, weight management techniques were all employed. And a serious ton of ibuprofen.
It was simply time for a new knee, a knee that would enable me to walk without restriction, to climb and descend stairs with an alternate gait, without discomfort or unease. Time to have the tool I needed to best enjoy my retirement of travel, gardening and physical exertion and long-term health.
This December I took a “trip of a lifetime.” Invited to attend an international women’s rights conference in Thailand, I followed that two-week amazing opportunity to meet remarkable women with a nine-day guided tour of Japan and a brief trip to Cambodia and the Angkor Wat temple area—all adventures included extensive temple and historic relic tours with their integral stairs, and seemingly random boulders. The trip was a month long and tested my ibuprofen supplies and walking sticks to their limit.
Yes, it was indeed time. I had scheduled my surgery prior to departure for January 2025, to take advantage of both my high-deductible pre-Medicare health insurance and my garden’s off season.
I’m not the sharpest knife in the drawer, but I do know how to count. ~ Mickey Gilley
So here I am, at 14 days remaining pre-op. (By the time-travel miracles of publishing, I should be done with my six-weekish home recovery and be walking with a cane as needed by the time you are reading this, although all well wishes are appreciated). Which brings us to the heart of this article.
I am counting down the days, off my NSAIDs, off my supplements (as most might lead anesthesia to put a last-minute kibosh on my procedure), on acetaminophen alone and creaking like the pre-lubricated Tin Woodsman ... but there’s still time to enhance my post-op outcome.
I’m stretching, beach walking, doing exercise class, yoga, gardening, eating a vegan/vegetarian diet. I am also engaging in knee “PREhab.”3
What’s that, you might ask? Studies indicate that starting your knee rehab in the PREperative period has a positive effect on pain and function out to six months postoperative, although the non-prehab group catches up in a year. Prior to visiting Asia, I had an intake visit with my local physical therapist, as the exercises in the pre-op brochure from my surgeon seemed elderly-level wimpy to me.
While doing my walking of Asia, I did my prehab exercises with bands in the hotel. With two weeks to go, like an athlete training for a marathon, I am kicking my prehab into high gear. I will do my prehab exercises three times daily, although I’ll be fair and substitute a round of prehab 1:1 with water aerobics, exercise class, and hauling loads of the mulch mountain inhabiting my driveway.
So, even though my management plans have changed to embrace the knife, in both pre- and post-op I play a major role in determining my knee outcomes.
“A knife is a humble tool that can create wonders in the hands of a skilled craftsman.” ~ Unknown
Know when to move on—when it’s time to embrace going “under the knife.”

### Personal Protective Equipment
OSHA’s regulation on occupational exposure to bloodborne pathogens requires employers to identify tasks and positions that might put employees at risk for exposure to blood and/or other body fluids, and to take appropriate measures to protect those employees from exposure. The regulation includes requirements for appropriate personal protective equipment (PPE). The type of PPE might vary according to the tasks to be performed. According to OSHA, however, the PPE selected must “not permit blood or other potentially infectious materials to pass through or reach the employee’s work clothes, street clothes, undergarments, skin, eyes, mouth or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used” (29 CFR 1910.1030).
The use of PPE is not optional.
It is the responsibility of the employer to provide the appropriate PPE, ensure it is used, and document and investigate failure to comply. All employees should be trained in both the appropriate protective attire to be worn for the tasks they perform and the potential health and disciplinary consequences if they fail to do so. This training should be documented and routinely verified as part of departmental competencies.
Recommended PPE
Because of the potential for soaking of clothing, splashing, and the aerosolization of fluids and contaminants, and the consequent need to protect employees from exposure to both microorganisms and chemicals, appropriate PPE in the scope cleaning area includes the following items (ANSI/AAMI ST91 2021):
 	General-purpose utility gloves and a liquid-resistant covering with sleeves (for example, a backless gown or surgical gown). Processing personnel should use a style of glove that prevents contact with contaminated water. Gloves that are too short, do not fit tightly at the wrist, or lack cuffs might allow water to enter when the arms move up and down. Exam gloves should not be used for decontamination. General-purpose utility gloves fitted at the wrist or above should be used.
 	A long-sleeved, impervious (fluid-proof) or fluid-resistant gown or jumpsuit. When there is a possibility that attire can become soaked with blood or other potentially infectious material, as when items are being washed by hand, a Level 4 gown (as defined by ANSI/AAMI PB70) should be used.
 	A fluid-resistant face mask and eye protection. PPE used to protect the eyes from splash could include goggles, full-length face shields, or other devices that prevent exposure to splash from all angles.
 	Fluid-protective shoe covers with slip-proof bottoms. Shoe covers are recommended when there is the potential for shoes to become contaminated with blood or other body fluids. Shoe covers should be removed before leaving the scope cleaning area in order to contain microorganisms and other contaminants (OSHA 29 CFR 1910.1030).
Reusable gloves, glove liners, aprons and eye-protection devices should be decontaminated, according to the manufacturer’s written IFU, at least daily and between employees. If the integrity of an item has been compromised, it should be discarded. Personnel should remove torn gloves and thoroughly wash their hands before donning new gloves. They should remove PPE worn during processing and wash their hands. Before handling disinfected endoscopes, personnel should don clean PPE (ANSI/AAMI ST91).
The PPE should be located as close to the entry of the scope decontamination room (if a two-room design) or at the entry to the soiled area of the scope processing room (in a one-room design). It is important that staff or visitors (e.g., service personnel) do not have to walk through the decontamination or soiled areas to don PPE. In storage, PPE should be protected from contamination (e.g., on a covered cart, in covered tote bins).
PPE should always be used in the scope cleaning area and when handling contaminated items. Not only is PPE required (OSHA), but just as important is the need to know how to appropriately don (apply) or doff (remove) the PPE to ensure staff is protected and do not contaminate themselves or their clothing. In an observational study published in the American Journal of Infection Control, JaHyun Kang and associates discovered that healthcare personnel contaminated themselves in almost 80 percent of the PPE simulations. Eighty percent.
Before leaving the cleaning area, employees should remove all protective attire—being careful not to contaminate the clothing beneath or their skin—and wash their hands. Per ANSI/AAMI ST91, designated areas with the necessary containers should be provided for donning and removing protective attire.
Staff members are not always educated and trained in the proper sequence for donning and doffing PPE. This information should be documented in the employee’s orientation guide.
According to the Centers for Disease Control, the correct sequence for donning and doffing PPE is as follows. This recommended sequence is based largely on 2004 CDC guidelines; however, the document does not address shoe covers.
Donning (Applying) PPE
1) The shoe covers should be donned first. Then wash your hands.
2) The gown should be donned next.
To don a gown, first select the appropriate type for the task and the right size. The gown should open in the back. Secure the gown at the neck and waist.
3) The mask should be put on next and should be properly adjusted to fit.
Some masks are fastened with ties, and others with elastic. If the mask has ties, place the mask over your mouth, nose and chin. Fit the flexible nosepiece to the form of your nose bridge. Tie the upper set of ties at the back of your head and the lower set at the base of your neck.
4) The goggles or face shield should be donned next.
Position either the goggles of the face shield over your face and/or eyes and secure it to your head using the attached earpieces or headband. Adjust it to fit comfortably. Goggles should feels snug but not tight.
NOTE: Safety eyeglasses are NOT a substitute for goggles or a face shield.
5) Gloves are donned last.
Insert each hand into the appropriate glove and adjust as needed for comfort and dexterity. If you are wearing an isolation gown, tuck the gown cuffs securely under each glove to provide continuous barrier protection for your skin.
Doffing (Removing) PPE
To remove PPE safely, it is first necessary to identify which sites are considered “clean” and which are considered “contaminated.” In general, the shoe covers, the outside front and sleeves of the gown, and the outside front of the mask and goggles or face shield are considered contaminated, regardless of whether there is visible soil. The outside of the gloves is also contaminated. Areas considered clean are the parts that will be touched when removing PPE: the inside of the gloves; the inside and back of the gown, including the ties; and the ties, elastic or earpieces of the mask and goggles or face shield. The sequence for removing PPE is intended to limit opportunities for self-contamination.
1) The shoe covers are considered the most contaminated pieces of PPE and are therefore removed first.
2) The gloves are next.
With a gloved hand, grasp the opposite glove and peel the glove off.Hold the removed glove in the gloved hand. Carefully slide the fingers of the ungloved hand under the top of the remaining glove (at the wrist) and peel that glove off over the first glove removed. Discard the gloves.
3) The goggles or face shield
Because the outside of the goggles or face shield is considered contaminated, remove the goggles or face shield by grasping the earpieces or headband. Using ungloved hands, grasp the “clean” earpieces or headband and lift them away from your face. If the goggles or face shield are reusable, place them in a designated receptacle for subsequent reprocessing. Otherwise, discard them in the waste receptacle.
4) The gown
Unfasten the gown ties with the ungloved hands. Slip your hands underneath the gown at the neck and shoulder and peel away the gown from your shoulders. Slip the fingers of one hand under the cuff of the opposite arm. Pull your hand into the sleeve, grasping the gown from the inside. Reach across and push the sleeve off the opposite arm. Fold the gown towards the inside and fold or roll it into a bundle. (Only the “clean” part of the gown should be visible.) Place the gown into a waste or linen container, as appropriate.
5) The mask
Do not touch the front of the mask to remove it. Untie the bottom tie and then, using the upper tie, lift off the mask. Discard it into a waste container.
6) Although not considered part of the PPE, the head cover should be removed last before you leave the decontamination area.
Lift the head covering off the head by grasping it in the center and lifting it upward. Discard in a waste container.
7) Thoroughly wash hands.
This procedure should be followed when personnel leave the scope cleaning room, and personnel should immediately wash their hands. Additional information on the removal of PPE can be found in Lisa Casanova’s PPE protocol published in the journal Emerging Infectious Diseases, which provides CDC’s recommendations. A poster depicting the process of donning and doffing PPE can be obtained on the CDC website (www.cdc.gov) and posted in your department.
PPE is required to protect staff members from an exposure to blood and/or body fluids. The type of PPE should be based on the potential for an exposure. Samples should be obtained before purchase or changing to another type of PPE to ensure it meets with the requirements. However, the correct procedures for donning and doffing PPE are just as important and need to be addressed for staff safety.

### Trust is the Foundation
Hudson Crossing Surgery Center (HCSC) in Fort Lee, New Jersey, is a multi-specialty surgery center that offers a variety of procedures, including sports medicine, spinal fusions, and cataract surgeries. The team also handles delicate cases like pediatric surgeries, according to Sterile Processing Department Lead Technician Alfonso Rodriguez. “One of our greatest sources of pride is our work with endoscopes,” Rodriguez said. “Our SPD department, while small, is highly efficient and equipped to tackle all sterilization needs.” The team consists of Rodriguez, and technicians Darius Rankin, Ronnie Ella and Jody Campbell.
Each team member is highly trained, with some certified as CRCST (Certified Registered Central Service Technician), and some seeking additional certifications as CHL (Certified Healthcare Leader) and CER (Certified Endoscope Reprocessor). (For more information on these certifications, see the Healthcare Sterile Processing Association’s website.) “Jody Campbell is our newest addition,” Rodriguez said, “and has already integrated seamlessly into the team.”
Some of the elements that make the Hudson Crossing team so effective include their talent, adaptability, shared values, and leadership, according to Rodriguez. “Each member brings unique expertise to the table, making our team a powerhouse of skills,” he said. “There’s a strong collective sense of purpose within the team, and we carry this through every task we perform. I strive to set clear goals, provide guidance, and inspire the team to stay focused. I empowereveryone to take the initiative and contribute to the team’s success.”
And, of course, trust.“Trust is fundamental to our success,” Rodriguez explained. “We’ve created an environment where each team member feels valued, respected, and supported. By fostering open communication and providing constructive feedback, we have built a team dynamic that thrives on mutual trust. Every member knows they can rely on each other, and that sense of camaraderie strengthens our performance.”
Hudson Crossing boasts a dedicated decontamination room that includes air and RO water hoses, a leak-testing machine to ensure insulation integrity, a Scope Buddy Plus machine for step-by-step cleaning, a CT digital borescope (scope inspector) for visual inspection, a protein tester kit for the inner chamber, a Medivators DSD Edge automated endoscope reprocessing system for high-level disinfection, and an Innerspace cabinet for safe drying and storage of endoscopes.
“Our team ensures that each endoscope is meticulously cleaned, inspected, and sterilized before returning it to the drying cabinet,” Rodriguez said.
He believes chemistry between team members is essential to a team’s success. While it can sometimes be a challenge, he said, “I believe that knowing how to handle weaknesses and embracing our differences helps create a supportive environment. I’ve worked with the team to ensure we approach challenges with a problem-solving mindset, fostering a culture of mutual respect. This has allowed us to overcome numerous obstacles, particularly when dealing with high-pressure situations or tight deadlines.”
Team member Darius Rankin said Rodriguez’s leadership makes a positive difference. “Alfonso has been a true leader to our team,” he said. “He’s always available to provide guidance, whether it’s on a technical issue or just offering support during a tough day. His calm and organized approach helps keep everyone grounded, even when we’re under pressure. I’ve learned so much from his leadership, especially how important it is to lead by example. He sets the bar high and encourages all of us to continually strive for excellence.”
But Rodriguez said he learns from his team, too, and one of the most important lessons is the value of continuous learning and adaptability. “In our field, things change quickly—whether it’s new technology, new procedures or new challenges. We all embrace this philosophy of lifelong learning, which helps us stay at the top of our game. Additionally, we all take pride in creating a safe and organized environment—from ensuring every scope is cleaned and sterilized properly to making sure that communication is clear and concise within the team. This commitment to excellence and attention to detail is what sets us apart.”

### A Sprinkle of Fairy Dust
Are you in search of assistance with digestive ailments, for yourself or your patients? If so, you may find an article on page 24 of interest that discusses a digestive enzyme known as FODZYME. It is a white powder that has the goal of alleviating digestive symptoms in individuals who are sensitive to foods with high levels of FODMAPs. What in the world are FODMAPs? They're fermentable carbohydrates (sugars) naturally present in some foods.
If individuals with irritable bowel syndrome eat FODMAP carbohydrates, they can experience symptoms of the digestive system. IBS affects one in seven people, and 70% to 75% experience relief of their symptoms on a low-FODMAP diet. The diet is useful but is a pain because it involves an elimination diet with an astonishing number of foods, some of which are nutritious. Once one knows which FODMAPs cause them the most issues, it's recommended that they eat less of them (or none at all). The silver lining, however, is that if one wishes for a solution beyond simply avoiding FODMAPs, a digestive enzyme by the name of FODZYME is available.
I've long believed that I'm sensitive to FODMAPs, so I began to play around with the FODMAP diet. The diet explained some enigmas for me. For example, I used to prepare a tasty salad that I felt wonderful about because it was healthy, but I always noticed that after 10 hours or so, I'd be bloated. So frustrating, because that salad was totally healthy! Greens, peaches, cherries, almonds and avocado. It blew my mind to discover that nearly the whole salad was high in FODMAPS.
I haven't given up any of those foods, but I do cut back on them. For example, I am a guacamole addict, but I now eat smaller servings of it. I believe these adjustments benefited my digestion, and now I have another weapon as well: FODZYME. It exists either in a jar or a box full of small, single-serve packets. The powder is sprinkled on food, or added in. I was dubious because it sounded yucky to sprinkle what I thought was medicine powder on my food. I thought it would ruin the texture and would definitely have a flavor. Sure, you can put some in water and drink it, but research indicates that the enzymes function optimally when sprinkled over food or added to it. So, okay, I tried the stuff.
Guess what? No taste. It literally doesn't taste. I have given some of the FODZYME to my mother—who has awful IBS and is a picky eater—and she agrees that there's no taste. I tried the "put it in water and drink it" method too, and that's the only time that it almost tastes. It also makes the water cloudy too, so no thanks. But on my food, it absorbs right into it. Even on my precious avocado. It's such a tiny amount of powder for a dose (about a quarter teaspoon) that it really isn't a problem. Now I sprinkle it on food as freely as salt. My young daughter questioned what it was, and I told her it was fairy dust.
Does it work? I believe so. Sure, the effects are difficult to monitor. I'm not exactly conducting a science experiment here—nor is my mom—but we both believe FODZYME has decreased our bloating. That was one of the main symptoms for both of us. Now that I know the stuff really works, I sort of enjoy sprinkling it. How else is my child going to think I have anything to do with fairies? In this issue there’s also an accompanying article about how to handle spicy foods if you’re following a low-FODMAP diet. Both these methods—the diet and the enzymes—are great tools and can work in conjunction, as well.

### Crohn's & Colitis Foundation Awards Doctor for Volunteer Leadership
ATLANTA—The Crohn's & Colitis Foundation has given its 2025 Rosenthal Award for Volunteer Leadership to Dr. Aja McCutchen. This honor recognizes volunteers who demonstrate exceptional leadership and make extraordinary contributions to improving the quality of life for patients and families affected by inflammatory bowel disease (IBD).
Dr. McCutchen is clinical chair of United Digestive, a leading physician practice-management organization serving GI physicians and gastroenterology practices nationwide. The Crohn's & Colitis Foundation highlighted Dr. McCutchen's high-impact volunteer service across nearly every aspect of its mission. Her contributions include facilitating support groups, leading the Atlanta Morning of Culture event, serving as a Torch Gala Premiere Physician, and being a prominent advocate within the IBD healthcare professional community.
"I am deeply honored to receive the Rosenthal Award from the Crohn's & Colitis Foundation," McCutchen said. "It has been a privilege to serve and advocate for IBD patients and their families. Seeing the resilience of this community inspires me every day, and I am grateful for the opportunity to contribute to the Foundation's vital work."
Dr. John Suh, chief medical officer of United Digestive, commended Dr. McCutchen on this remarkable achievement.
"Dr. McCutchen exemplifies the values of leadership, compassion, and dedication that United Digestive strives for every day,” Suh said. “Her commitment to improving the lives of IBD patients and advancing gastroenterology is inspiring. We are incredibly proud of her contributions to both the Foundation and our organization."
Dr. McCutchen received the award during the Crohn's & Colitis Foundation's Annual Volunteer Awards Dinner on March 6, 2025, in Charlotte, North Carolina.
 
 

### ESGE Releases Technical Guideline for Pancreatic Cyst Diagnosis
PARIS and BOSTON – The European Society of Gastrointestinal Endoscopy (ESGE) has issued a recommendation for the use of needle-based confocal laser endomicroscopy (nCLE) with Cellvizio for the characterization of pancreatic cystic lesions (PCLs)1. It is acknowledgement like this which allows for confident integration of nCLE in other areas like longitudinal monitoring of development in implanted pancreatic cysts in patients with sufficient expertise, which certainly underlined the need for such developers to assume standard clinical practice. The Cellvizio was developed by Mauna Kea Technologies, experts in multidisciplinary probe and needle nCLE.
Bertrand Napoléon, M.D., Department of Gastroenterology at the Jean Mermoz Private Hospital, Lyon, France remarked: “As far as the diagnostic approach to pancreatic cystic lesions, it has typically been more of a clinical dilemma because there are many conventional modalities and methods which still leave a great deal of ambiguity in the diagnosis and classification of some cysts. The addition of nCLE to the diagnostic pathway has remarkable benefits in diagnostic accuracy and patient outcome level. Certainly, the addition of nCLE to best practice guidelines for management of pancreatic cysts should not come as a surprise and is almost obvious after realizing all of the scientific evidence accumulated in the past decade.”
ESGE recommends nCLE as a differentiating method between mucinous and non-mucinous pancreatic cysts because it allows for the real-time visualization of tissue and blood vessels. This recommendation stems from nCLE’s vast evidence proving its diagnostic accuracy in comparison to a standard approach which relies on endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) without intervention.
Numerous multi-center studies using nCLE have reported high diagnostic accuracy. One study that was presented at Digestive Disease Week 2024 showed incredibly high sensitivity and diagnostic accuracy of EUS-nCLE for differentiating between mucinous and non-mucinous PCLs, which was 98%, and diagnostic accuracy which was 97%, which was significantly higher than CEA + cytology + glucose that had 77% and 80% respectively.
Further studies report that nCLE enhances both interobserver agreement and intraobserver reliability in the diagnostic assessment of mucinous lesions, serous cystadenomas, and pseudocysts, which is often difficult to achieve with standard diagnostic techniques. Furthermore, economic analyses show that the application of nCLE in the management of PCLs saves fourteen clinical hours per case, which corresponds to a 23% reduction in unnecessary surgeries, as well as an overall cost reduction of 13% in clinical expenses.
Sacha Loiseau, Ph.D., Chairman and CEO of Mauna Kea Technologies stated, “After ten years of development, we have proved that Cellvizio has the unparalleled ability to accurately characterize pancreatic cysts with close to 100% accuracy. This acknowledgement from the ESGE is the mark of a turning point of recognizing deep the role that the nCLE with Cellvizio will have on diagnosing pancreatic cysts. For the patients, it means less unnecessary surgery on indeterminate cysts, more rapid and precise diagnosis, and ultimately better results. For the providers of health care services, the adoption of nCLE into standard practice will be a big step forward in the improvement of precision medicine. As cysts of the pancreas merit concern in millions of people around the world and too much uncertainty remains with those who are currently diagnosing them, this recommendation is for widespread implementation, and will certainly be a game changer for many countries in terms of receiving financial reimbursement.

### The Increasing Prevalence of Pancreatic Cysts
By Dr. Arpan H. Patel
Pancreatic cysts are a rapidly increasing phenomenon in gastroenterology. According to the National Cancer Institute, age-adjusted rates for new pancreatic cancer cases have been rising, on average, 0.4% each year from 2009 to 2018. Keep in mind that this statistic does not include new discoveries of benign pancreatic cysts.
Increased patient imaging and the production of highly detailed images created by improved imaging technology have increased incidental findings of pancreatic cysts. About 50% of my referrals for endoscopic ultrasounds at this time are for patients who had a CT scan for something else and ended up discovering a cyst by chance.
However, the increasing prevalence does not mean all cysts pose significant danger to an individual’s health. At Middlesex Digestive, we are seeing an increase in cysts, but very few of concern. The frequency of large or high-risk cysts is minimal. In fact, more than 90% of cysts will be small and possess no high-risk features. Only about 10% will require further action through biopsies or surgery, and the standard rate of someone developing pancreatic cancer is only 0.5%.
There are several features we look for to determine whether a cyst is high risk. One of the most telling characteristics is size. Cysts that are greater than two centimeters in size are considered to have a greater likelihood of malignancy. The risk of an average cyst (less than two centimeters in size), converting into cancer is .01%. For cysts greater than 2 centimeters, the chance of malignancy can increase to 0.2%, which is still relatively low.
Those larger than 3 centimeters are considered particularly risky and will always be sampled to test for the presence of cancer. Other high-risk features include solid components on the cyst and nodules or thickened walls within the cyst. The involvement of the pancreatic duct to the point where it dilates or stretches is also a potential sign of malignant degeneration.
The most common type of cyst is the intraductal papillary mucinous neoplasm (IPMN) cyst, which accounts for 40% of pancreatic cysts. The IPMNs that tend to be precancerous are frequently asymptomatic in patients, which is partly why incidental findings have become more commonplace. If the cysts become large or obstructive, some patients may present with back pain, anorexia or weight loss, and fattier stools because they cannot process fat.
They may also develop diabetes. Jaundice can also result if the cyst blocks the individual’s bile duct. Solid pseudopapillary neoplasms (SPNs), in contrast to IPMNs, are almost always symptomatic. The individual may feel a weight in the abdomen, and may experience nausea, vomiting, or weight loss. The plan of action depends on what type of cyst the patient has.
Pancreatic cancer has a poor prognosis. The only curative intervention is surgery; chemotherapy only delays the inevitable. Large cysts or those with high-risk features are almost always biopsied to detect the possible cancer in its early stages. It’s very rare for a cyst to go straight to surgery without sampling, even with the presence of high-risk features. Sometimes large cysts are benign with no precancerous potential. For example, cysts that form as a result of excessive alcohol consumption can reach up to 10 centimeters in size (bigger than a baseball), but tend to have no precancerous potential.
The patient’s medical history and sampling of the cyst dictate how aggressive treatment needs to be. The presence of a solid component is the only instance in which a cyst may warrant immediate surgery, as solid cysts are three times more likely to turn into cancer than cysts without solid components.
Surgical cyst removal almost always involves the removal of part of the pancreas, which can be a large and complex operation. To remove the head of the pancreas, the surgeon must also remove the bile duct, small intestine, and stomach in a surgical intervention known as a Whipple procedure. Pancreatic surgery has the potential for complications given the sheer complexity of the surgery. Specialists need to have a complete handle on the nature of the cyst before sending patients to surgery.
Surgery is an option only if the cancer is discovered in its early stages, as more advanced disease will often involve the surrounding vasculature or nearby organs. The goal of pancreatic surgery is curative and, on occasion, if more advanced disease is discovered during a surgery, the case is often aborted. To prevent such discoveries, further imaging is usually done in advance of surgery to ensure the cancer has not metastasized.
The pancreas is a highly vascular organ containing critical blood vessels. If there is any involvement of the cancer with these blood vessels, the patient is not a good candidate for surgery. Borderline resectable candidates, where the cancer’s involvement with local lymph nodes or larger vessels is greater than is preferred, neoadjuvant chemotherapy can shrink the tumor to make the patient a better surgical candidate.
Unfortunately, due to the asymptomatic nature of cancerous IPMN cysts, many patients present late in the process, an unfortunate situation compounded by the fast-growing nature of the tumor. The transformation of the cyst from when it becomes malignant to when it becomes irremovable is rapid.
The most common way pancreatic cysts are diagnosed is with a routine CT scan: a frequent imaging modality that is used to help diagnose a variety of abdominal ailments. The pancreas is very well visualized on CT scans, so the presence of a cyst is clear; however, the characterization of the cyst (especially when it is smaller), including whether it has any high-risk features, is often not clear through a CT scan. In such cases patients are sent to a gastroenterologist to determine the next course of action.
Two important types of exams are performed on patients with large cysts: endoscopic ultrasound (EUS) and MRI. Both tests are more than 90% accurate in detecting and characterizing cysts, though EUS is thought to be more sensitive by a few percentage points. EUS has several benefits over MRI: not only does EUS provide a characterization of a cyst’s appearance, but it can also provide sampling in the same procedure.
To determine whether the cyst is a cancerous or precancerous IPMN, a fluid-based analysis is required to test for key tumor markers and genetic mutations to determine the individual risk for each patient. This is typically achieved by inserting a needle into the cyst, which can only be done through EUS or surgery. Surgery, however, is rarely used in biopsies today, as EUS offers a less complex and safer alternative. MRI helps characterize what a cyst looks like, but there is no choice but to sample with EUS anyway if it does have high-risk features.
While MRIs offer a noninvasive study of potentially dangerous cysts, EUS has become the gold standard of care for pancreatic biopsies. EUS is usually less expensive than MRI, and while there is a risk because of the sedation EUS requires, most risk is minimal. There is less than a 1% chance of tear or perforation, and antibiotics are given to combat any risk of infection as a result of the biopsy. EUS is also preferred for patients with pacemakers or metal in the body, who are ineligible for MRIs.
Smaller cysts or cysts with classically benign appearances are rarely biopsied and almost never surgically removed. In general, annual surveillance of pancreatic cysts for at least five years is recommended to ensure stability in smaller cysts. The consensus guidelines alternate EUS with MRI throughout the five years. At Middlesex Digestive, we often start with EUS if the cyst is greater than 2 centimeters to ensure it has no precancerous qualities.
One prevalent issue faced by gastroenterologists is the limited availability of EUS technology. Most US hospitals and clinics do not have EUS, so they must rely on imaging technologies like MRI to diagnose patients. Higher-volume communities may have EUS equipment and expertise, but many places—especially rural communities—do not have access to more advanced technology or, more importantly, experts trained in that technology.
Even in Massachusetts, a state renowned for its medical community, specialists proficient in EUS are relatively rare. Most physicians are now required to perform additional training after their gastroenterology fellowship to be able to get enough exposure to be proficient in endoscopic ultrasound. As applications to these programs increase, hopefully the growing number of trained professionals will spur more communities to invest in EUS technology.
Individual risk for pancreatic cysts varies greatly from person to person. Patients with familial or genetic risk have a higher likelihood of cancer. Genetic predisposition to cysts may result in a larger number of cysts and a faster timeline towards pancreatic cancer. BRCA mutations can increase the risk of developing pancreatic cancer, as can disorders such as Lynch syndrome and hereditary pancreatitis. Smokers and alcoholics are populations that warrant increased attention.
One notable improvement in the scientific community is the ability to test cyst fluid for genetic mutations that increase risk. This makes it easier to prognosticate the cyst’s risk for converting into a malignancy.
Debate exists as to whether more people are getting pancreatic cysts or whether their increased prevalence is due to more advanced imaging technology and medical practices; however, the past four decades have yielded a decrease in risky behaviors that have been proven to lead to pancreatic cysts.
One of the biggest risk factors for pancreatic cysts is tobacco use, with smokers twice as likely to get pancreatic cancer as nonsmokers. Despite a significant decrease in tobacco use in the United States since the 1970s, pancreatic cysts are more common than ever. The decrease in significant risk factors such as smoking suggests that advanced technology is at least partially responsible for the uptick in cyst discovery.
Some modifiable risks, however, have not decreased with time. In the United States, pancreatic cancer is the fourth leading cause of cancer-related death in the country. Excessive alcohol consumption is widely regarded as a significant risk factor, as are obesity and low levels of physical activity. Individuals with a BMI of at least 30 have a 1.7 times greater risk of getting pancreatic cancer than those with BMIs lower than 30.
The increase in pancreatic cysts often forces medical professionals to be objective about what the data states regarding cysts. Attempting to biopsy every cyst would overwhelm the healthcare system; it also increases the risk of complications for patients.
Personally, the increase in incidental findings has reminded me to take a step back and closely examine individual patient data and corresponding risk factors before sending a cyst to biopsy.
For many patients, cysts are not concerning at all. Nevertheless, because of the potential for cancer, there is concern for all patients who present with a cyst, regardless of its size. It’s important to discuss treatment strategies and reassurances regarding individual risk with each patient, those with both low- and high-risk features. Specialized, individual patient care is necessary to yield the best health outcomes for all.
Dr. Patel, a gastroenterologist at Massachusetts-based Middlesex Digestive Health & Endoscopy Center, has expertise in numerous areas of gastroenterology, including advanced interventional endoscopy procedures and therapies such as ERCP and ablative therapies for Barrett's esophagus, endoscopic ultrasound and managing complex bariatric (weight-loss) procedures.
Dr. Patel was accepted out of high school into Northwestern University’s Honors Program in Medical Education—a joint acceptance to both the undergraduate program and the University’s Feinberg School of Medicine—and received his medical doctorate in 2012. While an undergraduate, he received the J.G. Nolan Scholarship, given to students who have excelled in their studies, and in later years was honored as a Liver Emerging Scholar by the American Association for the Study of Liver Diseases and as a Chief Gastroenterology Fellow by the University of Michigan Division of Gastroenterology and Hepatology. Dr. Patel is licensed to practice in Massachusetts and six other states.
References
 	The American Cancer Society. June 9, 2020. “Pancreatic Cancer Risk Factors.” https://www.cancer.org/cancer/pancreatic-cancer/causes-risks-prevention/risk-factors.html
 	National Cancer Institute. “Cancer Stat Facts: Pancreatic Cancer.” https://seer.cancer.gov/statfacts/html/pancreas.html
 	National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. Centers for Disease Control and Prevention. 2014. “The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General.” https://www.ncbi.nlm.nih.gov/books/NBK294310/
 
Dr. Arpan H. Patel 
Dr. Patel, a gastroenterologist at Massachusetts-based Middlesex Digestive Health & Endoscopy Center, has expertise in numerous areas of gastroenterology, including advanced interventional endoscopy procedures and therapies such as ERCP and ablative therapies for Barrett’s esophagus, endoscopic ultrasound and managing complex bariatric (weight-loss) procedures.
Dr. Patel was accepted out of high school into Northwestern University’s Honors Program in Medical Education—a joint acceptance to both the undergraduate program and the University’s Feinberg School of Medicine—and received his medical doctorate in 2012. While an undergraduate, he received the J.G. Nolan Scholarship, given to students who have excelled in their studies, and in later years was honored as a Liver Emerging Scholar by the American Association for the Study of Liver Diseases and as a Chief Gastroenterology Fellow by the University of Michigan Division of Gastroenterology and Hepatology. Dr. Patel is licensed to practice in Massachusetts and six other states.

### Q&A With Cedars-Sinai Researcher, Pioneer in Gut Microbiota
Ivan Vujkovic-Cvijin, PhD, is a pioneer in the study of the gut microbiota and the surprising ways these microorganisms living in our digestive tracts affect our overall health. His discoveries have been featured in Nature, Science Translational Medicine, Cell Reports and other top scientific journals.
In his latest achievement, he landed a $2.7 million, five-year grant from the National Institutes of Health to investigate whether microbiota dysfunctions are contributing to the elevated risk of hypertension in HIV patients.
“Vujkovic-Cvijin exemplifies the energy and ambition of Cedars-Sinai’s research scientists,” said David Underhill, PhD, chair of the Department of Biomedical Sciences at Cedars-Sinai, where Vujkovic-Cvijin is an assistant professor in the Karsh Division of Gastroenterology. “His highly innovative and pioneering studies underlie the importance of his scientific work.”
The Cedars-Sinai Newsroom recently sat down with Vujkovic-Cvijin to learn more about his work and how his findings could potentially help patients
How does the gut microbiota influence other bodily systems and processes?
The gut microbiota is the community of trillions of bacteria, fungi, viruses and other microbes that live in our digestive system. These microbes play a critical role in keeping us healthy by supporting immune function, keeping harmful microbes at bay and by breaking down our food. The breakdown of foodstuff can have potent effects on several systems within our body. One key example is the microbial breakdown of dietary fiber. Gut microbes convert fiber into molecules known as short-chain fatty acids, which are thought to provide wide-ranging health benefits, including tamping down overactive immune cells, strengthening our gut lining and preventing high blood pressure, or hypertension.
What is different about the gut bacteria in people with HIV, the virus that causes AIDS? 
The gut microbiota of these patients is altered in various ways, particularly in a reduced ability to metabolize fiber into short-chain fatty acids. A decrease in microbes responsible for this process could be one of the reasons that people with HIV, even on therapies that nearly eliminate the virus, continue to experience immune-related diseases including hypertension.
Can you share with us some of the direction of your current research?
First, we want to learn if the problem with metabolizing fiber might help explain why hypertension and cardiovascular disease occur at substantially greater rates in patients who have been treated for HIV. We plan to investigate the dynamics of fiber metabolism and uptake in people living with HIV and the role that these processes may play in producing cardiovascular illness.
Second, we want to use our findings to explore how we might restore the capacity for fiber metabolism in HIV patients to enhance production of short-chain fatty acids. Our methods will include animal models, computational biology and an array of powerful “omics” technologies, which enable us to process large amounts of biological data.
How could this research help patients?
Understanding how an altered gut microbiota may contribute to cardiovascular diseases will be important for designing new ways to possibly prevent these illnesses in people living with HIV or to reduce their severity. People with HIV often have endured a lot. We want to help them live long and healthy lives.
In addition, because HIV patients experience heightened rates of aging-related diseases, our findings may be broadly pertinent to the biology of healthy aging in the general population.
What is the next step in this research?
We will seek to identify dietary components that we could use to help reverse some of the cardiovascular risks in people with HIV. It would be a huge advance if we could help HIV patients reduce their chances of developing heart disease by adjusting their gut microbiota or their diets.

### National Survey: Many Americans Unaware of Genetic Colon-Cancer Risk
CLEVELAND—New research recently released by Reese Pharmaceutical reveals that thousands of Americans could be at high risk of colon cancer but not realize it.
The survey found that 80% of U.S. adults do not know whether a first-degree relative (parent, sibling, or child) has been diagnosed with colorectal cancer (CRC). Studies show people who have an immediate family member with CRC are 2 to 4 times more likely to develop the disease compared to those who don’t.
“The data proves there is a significant gap in awareness that could be contributing to an increase in colorectal cancer rates. Knowing your family history is crucial because the information can be used to determine how early and often you need to get screened, which can aid in prevention and treatment,” said Jeff Reese, president of Reese Pharmaceutical.
Colorectal cancer is now the leading cause of cancer deaths among men under the age of 50 and the second leading cause for women in the same age group. For younger people, rates have increased by 1% to 2% each year since the mid-1990s.
“My husband passed away from colon cancer at age 45,” said Yvette Davis-Atkins, who now serves as an ambassador for Fight Colorectal Cancer, a patient empowerment and advocacy organization. “My son was only 12 years old then, but he started getting screenings right away. He’s being monitored so we can catch any issues early when they are more treatable. The approach could ultimately save his life.”
To encourage others to be more proactive in learning about their family’s history of colorectal cancer, Reese Pharmaceutical is launching a new educational campaign, “Know Your CRC History.” The social media campaign will encourage the public to share stories on Facebook and Instagram using the hashtag #MyCRChistory. It will also include information on the various colorectal cancer screening tools now available, including at-home fecal immunochemical tests (FIT tests), such as ColoTest, that can be used annually and deliver immediate results. A recent study by Kaiser Permanente found that FIT-test screening reduced the overall risk of colon cancer death by 33%.
Reese’s survey found most consumers remain unaware of over-the-counter (OTC) tests like ColoTest, and only 3% say they have ever used them. The tests are an easy way to detect hidden blood in the stool, a key warning sign of colorectal cancer (among other conditions). A majority of those surveyed also said they would reach out to their doctor if an at-home test came back positive, suggesting a need to educate doctors and pharmacists about the various at-home options as well.
“The early detection and monitoring of colorectal cancer is beneficial in reducing mortality rates by detecting cancer at an earlier, more treatable stage,” said Bernard Esquivel, M.D., PhD, Chief Medical Officer at the diagnostic platform ixlayer. “As a physician with extensive experience in patient care, I can attest that fecal-based tests are a well-documented and widely accepted practice.”
According to ixlayer, 83% of physicians believe at-home testing can help move patients through the care continuum faster, accelerating the path to diagnosis and improving health outcomes.
Based in Cleveland, Ohio, Reese Pharmaceutical Company is a private-label manufacturer of OTC consumer health products. The company also produces a variety of branded items, such as ColoTest, a noninvasive at-home test designed to help screen for colorectal cancer.

### AJG Publishes Results from Pivotal Barrett’s Esophagus Study
BALTIMORE—Previse, a gastrointestinal health company, announced recently that its clinical validation study results for its flagship assay, Esopredict, were published in the American Journal of Gastroenterology (AJG). The study, “Validation of an Epigenetic Prognostic Assay to Accurately Risk Stratify Patients with Barrett’s Esophagus,” highlights Esopredict, a first-in-class DNA methylation test for identifying patients with precancerous Barrett’s esophagus (BE) who are likely to progress to high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) in the future.
“Effective treatments are available for patients with Barrett’s esophagus,” said Sarah Laun, PhD, vice president of research and development. “However, gastroenterologists have lacked access to an epigenetic tool that identifies patients likely to progress towards cancer. Esopredict enables clinicians to identify high-risk patients earlier, allowing them to intervene and treat sooner, potentially saving patients’ lives.”
Esopredict is the first and only epigenetic assay to predict the likelihood of a person diagnosed with BE of progressing to HGD or EAC within five years. Esopredict analyzes DNA methylation levels, an early indicator of disease progression or cancer that often precedes morphologic changes. Each result includes a personalized risk score and a patient’s probability of progression.
The retrospective study included 240 patients whose esophageal biopsy samples were collected across six U.S. clinical sites, including Allegheny Health Network, Capital Digestive Health Specialists, Johns Hopkins University, Mayo Clinic, University of Connecticut, and University of Maryland. Patient samples were processed at Previse’s CLIA laboratory in Baltimore, Maryland. Each sample was analyzed to quantify DNA methylation levels using biomarkers that were integrated into a predictive algorithm to determine each patient’s likelihood of progressing to HGD or EAC within five years. The algorithm was locked and tested on an independent validation set.
Study results were remarkable in demonstrating that patients identified by Esopredict as high risk had an average risk of progression of 22% within five years, 4 times more likely than the average risk based on prevalence to progress to HGD or EAC, while low-risk patients reflected only a 1.9% risk, with a modeled negative predictive value of 99%.
“This study represents a major leap forward for the care of patients diagnosed with Barrett’s esophagus,” said senior author and Previse cofounder and advisor, Dr. Stephen J. Meltzer. “This study represents that for the first time, we can offer gastroenterologists a precise, quantitative and tailored approach to personalize surveillance and treatment management decisions.”
According to Previse, Esopredict is exceptional among molecular diagnostics innovations, as it is uniquely designed to focus on epigenetic biomarkers: chemical changes to a patient’s DNA that control gene expression. Such DNA methylation alterations often occur early, before neoplastic changes emerge. By quantitatively measuring these changes and stratifying patient risk, Esopredict complements traditional BE management by allowing gastroenterologists to use esophageal biopsy tissue that is routinely collected during a patient’s surveillance endoscopy, including archived tissue.
“We are excited about Esopredict’s timing and ability to change the paradigm in BE surveillance and treatment,” said Daniel Lunz, chief executive officer and cofounder of Previse, “as esophageal cancer rates have continued to climb and claim more lives each year.”
 

### Gut Microorganisms May Play a Role in Constipation
Microorganisms in the gut can trigger constipation in some people, according to study published recently in Clinical Gastroenterology and Hepatology. The study showed that disruption in a patient’s gut flora, specifically the overgrowth of archaea (unique microorganisms in the gut microbiome that produce methane) could be the cause.
Researchers hope the study’s findings will help experts root out the cause of constipation instead of merely treating patients’ symptoms. These findings could also aid in developing a personalized treatment plan for a subgroup of patients who experience severe constipation due to intestinal methanogen overgrowth (IMO)—a condition in which archaea excessively grow in the intestines.
“Our study found that patients with IMO are more likely to have constipation, particularly severe constipation, and less likely to have unyielding diarrhea,” said the study’s corresponding author, Ali Rezaie, MD, medical director of the Cedars-Sinai GI Motility Program and director of Bioinformatics at the Medically Associated Science and Technology (MAST) program at Cedars-Sinai. “Patients, however, also reported several other gut-related symptoms, including bloating, diarrhea, abdominal pain and flatulence.”
Constipation is one of the most common gut-related issues in the United States. About 16% of adults experience bloating, abdominal pain, and difficulty having bowel movements; the numbers nearly double for people over 60. While many things, like medication side effects or lack of dietary fiber, can cause constipation, historically, there has been a shortage of research on the gut microbiome’s role in constipation and other digestive issues.
“When there is an excessive amount of archaea in your gut, they produce more methane, and some of that methane makes its way to your bloodstream, then to your lungs, and you breathe it out, where it can measured as a diagnostic test,” Rezaie said. “Essentially, people who have excessive amounts of methane have a lot of GI symptoms, including constipation, flatulence, bloating and diarrhea.”
For context, the gut microbiome consists of trillions of microorganisms, such as the community of bacteria, yeast and fungi in the digestive system. When there is an imbalance among the microorganisms populating the gut, it is associated with a host of GI symptoms and diseases.
Experts used electronic databases to identify 19 studies (11 conducted in the U.S. and eight conducted in six other countries) that assessed symptoms for patients with IMO.
“Historically there has been a paucity of information regarding the role of archaea in health and disease. Unique symptom patterns related to IMO should be taken into account when measuring patient-reported outcomes and should be further studied in relation to the microbiome,” said Peter Chen, MD, interim chair of the Department of Medicine at Cedars-Sinai.
For example, taking over-the-counter or prescription laxatives often relieves constipation, but won’t always address other GI symptoms, such as bloating, abdominal pain and diarrhea. In fact, in some cases, taking a laxative could potentially worsen coexisting diarrhea and bloating.
Researchers explain that the optimal solution for IMO-induced severe constipation is to suppress the archaea overgrowth and keep the organism at bay. This generally involves a combination of antibiotics and a specialized diet to reset the gut microbiome. However, the first step is to diagnose the archaea overgrowth through a noninvasive hydrogen/methane breath test.
According to Rezaie, the study's findings are crucial and will hopefully encourage healthcare providers to utilize precision medicine, conduct clinical trials that target microbiome research and develop strategies to optimize patient care.
“The goal is to move toward developing specific therapies and personalized treatment for a subgroup of people who experience constipation due to IMO,” Rezaie said. “We can start by using breath tests to identify excessive methane production, which can be the first step to detecting archaea overgrowth and could ultimately lead to developing more targeted therapies. It's a big step to move away from the common reflex use of laxatives.”
 

### Inhale, Exhale: Breath Testing for SIBO
Our small intestine is host to a finely tuned microbiota machine, performing countless functions to digest and process stomach contents and move things toward the large intestine. But any imbalance in this tiny ecosystem can throw a cog in the machine—including bacteria.
Paulina Roszkowska and associates wrote in a review in Biomedicines that “SIBO is defined as an increase in the number of bacteria (103–105 CFU/mL), an alteration in the bacterial composition, or both in the small intestine.” Symptoms can include chronic diarrhea, weight loss, malabsorption, nutritional deficiencies and osteoporosis. Or they can be as common as bloating, distension, fatigue and weakness. Severe cases can present with steatorrhea.
Complications include malabsorption and fat-soluble vitamin deficiencies leading to neuropathy. But as with so many disorders, these symptoms can indicate other diseases, too, which is why a substantive diagnosis is so important.
Working For a Living
We already know that our intestinal microbiota play a significant role in the body’s immune function. To riff on a catchphrase, “If the gut ain’t happy, ain’t nobody happy.” Our microbiome works hard to ensure the gut’s “happiness” and efficacy. It not only breaks down food, empowers metabolism and enables the synthesis of certain nutrients, but it also protects the body against potentially pathogenic bacteria.
Put simply, our microbiome is full of a spectrum of amazing multitaskers. And this team never takes a vacation.
But our happy microscopic community can be affected by many factors, including the host’s age, food choices, use of pharmaceuticals, lifestyle and stress, among others. Starting in the mouth, which can host up to 700 species of bacteria, the microbiome alters in size and composition in the stomach, small intestine, large intestine and colon. Stomach acid kills off a lot of interlopers, but it’s in the intestines where things really get interesting, with the number and diversity of microorganisms increasing as the food progresses through digestion. Bacteroides, Lactobacillus and Streptococcus species dominate the jejunum, while in the ileum, microorganisms such as Enterococcus, Veilonella and Enterobacterales join the party. By the time we’ve arrived at the large intestine, we’re sharing space with about 800 species of symbiotic, opportunistic, and pathogenic bugs, predominantly anaerobic.
In SIBO, we see a proliferation of small intestinal bacteria, including those “Gram-negative aerobic and anaerobic species,” according to Roszkowska, et al. “In the physiological state, there are mechanisms to prevent excessive colonization of bacteria in the small intestine, such as acidic stomach pH, pancreatic enzymes, the intestinal immune system, small intestine peristalsis, the ileocecal valve, and the intestinal barrier itself. However, when changes in any of these mechanisms occur, SIBO can develop.”
And develop it does. For such a diverse community, it doesn’t take much to throw the system out of whack.
Historically, it was thought SIBO presented only when there was some type of anatomical abnormality or trauma, motility disorder or post-surgery issue. But according to Andrew Dukowicz, Brian Lacy and Gary Levine, SIBO may be much more common than previously thought. They wrote, “...although data are limited, the prevalence rates of SIBO in young and middle-aged adults appear to be low, whereas prevalence rates appear to be consistently higher in the older patient (14.5–15.6%); these rates, however, are dependent upon the diagnostic test used (see below).   A number of diagnostic tests are currently available, although the optimal treatment regimen remains elusive.”
According to Irina Efremova and associates, SIBO can be associated with a laundry list of previously existing conditions, including functional dyspepsia, IBS, abdominal bloating, constipation, diarrhea, short bowel syndrome, chronic intestinal pseudo-obstruction, lactase deficiency, diverticular and celiac diseases, ulcerative colitis, Crohn’s, cirrhosis, metabolic-associated fatty liver disease (MAFLD), primary biliary cholangitis, gastroparesis, pancreatitis, cystic fibrosis, gallstone disease, diabetes, hypothyroidism, hyperlipidemia, acromegaly, multiple sclerosis, autism, Parkinson’s, systemic sclerosis, spondyloarthropathy, fibromyalgia, asthma and heart failure, among others.
The disorder can be especially pernicious in patients with Crohn’s disease, according to Anna Greco and associates, because it mimics a Crohn’s flare. Renal failure can cause SIBO, as can chronic alcohol use. But something as simple as antibiotic use or a disturbance in the gut’s immune function can catapult a patient right into SIBO.
Once the imbalance is created, the body’s inflammatory response can make the problem even worse and foment bigger issues. “Analysis of small bowel biopsies in elderly patients with bacterial overgrowth revealed blunting of the intestinal villi, thinning of the mucosa and crypts, and increased intraepithelial lymphocytes,” Ducowicz, et al., wrote, noting that antibiotic treatment reversed the symptoms.
Motility disorders are a red flag for SIBO. Gastroparesis—a problem for long-term diabetics or those with connective tissue disorders, a viral infection, or ischemia—can lead to SIBO. And Ducowicz, et al., wrote, “Impaired gastric peristalsis can lead to SIBO due to stasis of food and bacteria in the upper GI tract.” Anything that delays that gastric emptying can feed the problem—hence, the laundry list.
People who are immune deficient are also at higher risk. However, Ducowicz and associates wrote, “Patients with deficiencies in humoral or cellular immunity do not appear to be predisposed to SIBO, as they have normal intestinal microflora.”
One element frequently overlooked in diagnosing and treating SIBO is also the most pernicious element of Western culture: diet. In the journal Nutrition, Eliza Knez and associates wrote that, aside from the anatomical and physiological factors interfering with the myoelectric motor complex, the activity of gastrointestinal transit is conditioned by diet. “Indisputably,” they wrote, “the Western type of nutrition is unfavorable.” Food affects the microbiome, “and diet should prevent bacterial overgrowth and exhibit antimicrobial effects against pathogens. Therefore, knowledge about proper nutrition is essential to prevent the development and recurrence of SIBO.”
Trouble In Paradise
The test for diagnosis generally has been a small bowel jejunal aspirate of >10 5 CFU/ml, according to Hammad Zafar, Brenda Jimenez and Alison Schneider in Current Opinion in Gastroenterology. But this method has drawbacks, including cost, invasiveness, and the potential for sample contamination by oral and pharyngeal flora—the lab equivalent of stomping all over your birthday cake with hiking boots. Determining a positive aspirate is tricky. Additionally, wrote Roszkowska, et al., “the standard processing of material in the microbiology laboratory does not allow for the detection of all gut microbiome species.
“New molecular techniques based on sequencing of the 16S ribosomal RNA gene (which is present in all bacteria) and metagenomic approaches have recently been introduced to overcome the shortcomings of current SIBO testing methods,” they added. “This is expected to lead to the discovery of new bacterial species, as well as a better understanding of their involvement in SIBO and the associated impacts on related diseases.”
That said, glucose and lactulose breath testing offer advantages such as ease of accessibility, lower cost, and its noninvasive nature, which is making this test more common in clinical settings. These recent advances in testing—which also include capsule and urine-based testing—have improved the diagnostic yield in SIBO.
Another perk of the breath test is that it can be performed at home—a definite benefit for those concerned about Covid-19 and other disease transmission, and/or those with patients who have compromised immune systems. (See Commonwealth Diagnostics International website at commdx.com for more information.)
Dukowicz wrote, “All breath tests rely on the recovery and quantification of an exhaled gas produced by the bacterial metabolism of the ingested substrate. The development of inexpensive, commercially available gas chromatographs to measure exhaled hydrogen and/or methane has led to the widespread use of breath testing for the diagnosis of bacterial overgrowth.”
The ease of the breath test makes it especially appealing for pediatrics (although most adults certainly wouldn’t say no to avoiding an endoscopy). The patient ingests 10 grams of lactulose or 75 grams of glucose, then spends the next three hours exhaling into a breath analyzer at 20-minute increments. The analyzer is testing for the presence of hydrogen or methane. Generally, glucose simply gets sucked up by the small intestine. But when SIBO is present, the bacterial overgrowth causes fermentation, which results in gas—roughly 20 percent of which ends up being metabolized through the lungs. If hydrogen rises 20 ppm above baseline for 90 minutes, or if methane is greater than or equal to 10 ppm at any time within two hours, you have your first criterion.
The second check mark you’re looking for is the “double peak,” wrote Roszkowska, et al., “which consists of an initial hydrogen peak before 90 min, then a decrease of more than 5 ppm in two consecutive samples, followed by a second hydrogen peak when the substrate enters the cecum.” This gives you your diagnosis.
This is assuming your patient does their prep correctly and remembers to avoid antibiotics for four weeks before the test, as well as drugs that accelerate intestinal peristalsis and have a laxative effect. The day before the test, patients should not consume complex carbohydrates and alcohol; and they should plan to fast from food, exercise and smoking for 8-12 hours beforehand. Roszkowska, et al., observed, “Brushing the teeth and rinsing the throat before the test can minimize lactulose fermentation by bacteria in the mouth.” (Commonwealth Diagnostics International recommends diabetics avoid this test because of the fasting involved, as well as the amount of absorbable sugar used.) So while the prep isn’t easy, it is doable—especially given the “carrot” of avoiding a more invasive test.
Some researchers have argued that the two breath tests—lactulose vs. glucose—are not equal. In a retrospective study, Francois Mion and associates discovered that in a cohort of irritable bowel syndrome (IBS) patients, lactulose provided a much higher prevalence of SIBO diagnoses than glucose did. Based on this, they wrote, “Lactulose breath test should not be used anymore for the diagnosis of SIBO.” They speculated that the lactulose breath test yields a more frequent diagnosis “because of its limited small bowel absorption, and therefore colonic fermentation.”
A 2024 evaluation of small capsule bacterial detection system (SCBDS) indicates the technology is promising; Shaoying Nikki Lee and associates stated the system merits further investigation. And while a urine test also offers ease of use, it can also be easily contaminated, skewing the results.
Substantive research and clinical judgment are indicated when determining what tests will work best for patients.
If This Is It
Treatment is multifactorial and also should be tailored to the patient. Anatomical defects (fistulas, adhesions, diverticulosis, obstructions and strictures) should be corrected first, and initial infection treated with antibiotic therapy. Dukowicz wrote, “The two processes that most commonly predispose to bacterial overgrowth are diminished gastric acid secretion and small intestine dysmotility,” so drugs that interfere with gastric motility or acidity, such as PPIs, should be reduced or eliminated.
Thanks to the challenges inherent in obtaining an untainted specimen, practitioners generally rely on metronidazole, ciprofloxacin, tetracycline, amoxicillin-clavulanate, neomycin, or rifaximin to knock out the intestinal overgrowth. In some cases, practitioners have used prokinetic drugs to accelerate intestinal motility.
But antibiotics aren’t a magic bullet, and they can present other problems (including wiping out good bacteria with the bad and actually exacerbating the infection). According to Melissa Nickels and associates, SIBO can bounce back from antibiotic therapy. Their February 2021 review in the Journal of Alternative and Complementary Medicine indicated that “probiotics, therapeutic diets, and herbal medicines have been used to individualize SIBO management, particularly in recalcitrant cases,” and they called for more large-scale, randomized, placebo-controlled trials to better evaluate the efficacy of alternative therapies in SIBO management.
Greco, et al., found that, despite being underestimated because it mimics a Crohn’s flare, SIBO responds positively to antibiotic and probiotic therapy.
In a review in the Clinical Journal of Gastroenterology, Changqing Zhong, et al., showed thatwhile probiotics supplementation was ineffective in preventing SIBO, the treatmentdid effectivelydecontaminate SIBO, reduce hydrogen gas concentration, and relieve abdominal pain. And Lucia Redondo-Cuevas and associates followed up with a 2024 randomized controlled trial, published in the journal Nutrients. They found that an intervention group that received herbal antibiotics, probiotics and prebiotics in addition to standard antibiotic therapy and a low-FODMAP diet showed higher clinical remission rates than the control group.
SIBO is a multifaceted problem that may require a tailored and multifaceted solution. Breath testing is just the first step in getting a patient on the road to recovery.

### AI Is Reshaping Healthcare
Artificial intelligence (AI) is rapidly reshaping healthcare. From diagnostics to patient care and administrative processes, AI is positioned to revolutionize the industry. Nine out of 10 organizations believe AI offers a competitive advantage.1 However, despite all the optimism surrounding its limitless possibilities, 70% to 80% of all AI projects fail.2 This rapid pace of change has left many healthcare professionals scrambling to adapt, facing a steep learning curve and significant role evolution. Many tasks traditionally performed by humans are now shared with or are entirely managed by AI, which has profound implications for daily operations and workforce dynamics.
The stats are striking: 43% of healthcare professionals feel they lack the skills necessary to thrive in an AI-driven landscape.3 This isn’t just a skills gap; it’s a pervasive sense of insecurity and disruption. A survey conducted by the American Psychological Association claims that 38% of U.S. workers are worried that AI could eventually take their jobs. Among these, 51% report work-induced mental duress, and 46% are considering seeking new employment.4 These figures highlight that, when implemented poorly, AI represents progress and opportunity for some, while for others, it’s a source of uncertainty, amplifying fears of obsolescence and compounding existing stress levels. Bridging that divide is essential for the healthcare field to move forward effectively—for workers and patients.
AI Skills Gap in Healthcare
AI anxiety isn’t just about technology. It’s about continually acquiring new skills, adapting to more complex job demands, and reconciling these changes with existing workflows. A recent survey shows that 61% of healthcare professionals feel overwhelmed by the need to upskill and meet AI’s demanding learning curve.5 This anxiety isn’t unfounded—AI doesn’t just augment tasks; it transforms them, making roles more dynamic yet often more complex.
According to a recent report, 67% of healthcare leaders are aware of the growing skepticism among employees regarding AI.6 They recognize that this is often accompanied by burnout and stress as professionals juggle existing responsibilities with the pressure to adapt to AI. Leaders face the daunting challenge of fostering a supportive environment while also championing technological advancements.
A significant trust gap exacerbates the AI skills gap: 46% of healthcare workers report a lack of trust in their leadership during this transition.7 This distrust often results in higher turnover rates, as employees seek stability elsewhere rather than navigate uncertain waters. This is particularly problematic in an industry where consistency and employee retention are critical to delivering high-quality patient care.
The Financial Stakes of AI Adoption
On paper, AI adoption is a no-brainer for any business, including healthcare organizations looking to cut costs. Through improved efficiency and automation, AI could save the healthcare industry $150 billion annually by 2026.8 However, these savings are contingent on successful implementation and adoption. AI’s potential benefits may never fully materialize without a properly trained workforce.
Companies should take a pragmatic and strategic approach to reducing the financial risks tied to the high failure rate of AI projects. This means carefully choosing options that closely align with business goals and offer clear, measurable results. High-impact, feasible projects that can deliver quick wins can help build confidence and attract further investment.
There’s a compelling financial case for investing in AI literacy. The cost of replacing employees is up to six times higher than the cost of retaining employees through retraining.9 For hospitals with an annual turnover rate of 21%, this can translate to significant financial loss.10 Without adequate AI literacy programs, organizations face the risk of losing skilled employees to burnout or job dissatisfaction, which could undermine the very efficiency gains AI promises.
The Need for AI Literacy Programs
Properly implemented AI literacy programs can bridge the trust gap between employees and leadership, reducing turnover and enhancing morale. Training provides a sense of stability and shows employees that they are valued and supported. In fact, 57% of employees are actively seeking AI training from their employers, indicating a willingness to engage with AI if properly guided.11
AI-trained teams not only experience a boost in morale but also see productivity gains of up to 40%.12 As a result, AI literacy programs offer a dual advantage—enhancing both employee well-being and operational efficiency. For healthcare organizations, developing a workforce skilled in AI technology leads to improved patient outcomes, more streamlined operations, and a stronger competitive position in an increasingly AI-driven market.
The Case for Reskilling
In the rapidly evolving landscape of healthcare, AI is more than just a tool for innovation—it’s a catalyst for sustainable growth. However, for AI to truly deliver its transformative potential, healthcare organizations must prioritize AI literacy within their workforce. AI disruptions should present opportunities for proactive reskilling and upskilling. Instead of reshuffling headcount, healthcare leaders should invest in AI literacy programs that equip their existing teams with the skills needed to navigate AI-driven changes.
AI has the potential to streamline tasks, reduce operational costs, and enhance patient care. Yet, these benefits hinge on having a workforce that can adapt to AI’s complexities. By investing in AI literacy, healthcare organizations can preemptively address the challenges posed by AI, fostering a more resilient and skilled workforce.
Navigating AI Adoption Effectively
Skepticism toward AI is common, particularly in healthcare, where professionals may worry about AI’s reliability, ethical implications, and impact on patient care. Building trust starts with transparency—leaders should clearly communicate AI’s role, benefits, and limitations. Additionally, including employees in AI adoption strategies can foster a sense of ownership and mitigate fear of the unknown.
Healthcare professionals often face significant hurdles when moving from familiar legacy systems to AI-powered platforms. The transition can be overwhelming, requiring employees to adopt new workflows, understand data-driven decision-making, and manage AI-enhanced tools. AI literacy programs can ease this transition by offering education that builds technical skills and confidence. This would enable employees to embrace AI with fewer disruptions.
As AI automates routine tasks, healthcare professionals may feel their roles are at risk. To retain talent, organizations should communicate AI’s role as an augmentative tool rather than a replacement. Upskilling programs that emphasize how AI can complement human skills help employees see AI as a valuable ally, not a threat, which can boost retention and engagement.
Effective AI transformation requires a holistic approach, where a commitment to human development matches technological advancements. By focusing on reskilling, organizations can balance AI’s efficiencies with the need to cultivate a knowledgeable and adaptable workforce. This holistic approach nurtures trust, boosts morale, and supports long-term career development.
The Path Forward for Healthcare
Ultimately, AI is a transformative force with immense potential for healthcare, but it also poses significant challenges if not managed well. Organizations that invest in AI literacy programs and prioritize their workforce will be better positioned to harness AI’s full benefits. The stakes are high, and healthcare leaders must tread carefully, balancing innovation with compassion and foresight.
For healthcare organizations to thrive in the AI era, leaders need to take a proactive stance on AI literacy. Implementing comprehensive training programs is no longer optional; it’s a necessity. By preparing their workforce for the future, healthcare organizations can not only mitigate the risks of AI disruption but also lay the groundwork for a more resilient, productive, and engaged workforce that’s ready to navigate the complexities of an AI-driven healthcare landscape.
Maintaining a competitive edge in today’s AI-driven landscape requires a purposeful approach. It’s not simply about getting on board with the latest technology; it’s about bending it to align with your strategy and desired business outcomes while ensuring your AI data readiness supports a roadmap that leads straight to success.
Ultimately, a sustainable AI transformation in healthcare must extend beyond technology to include the human elements of trust, morale, and professional growth. By investing in AI literacy programs, healthcare organizations can build a workforce prepared to navigate the future—ensuring that AI’s transformative potential benefits both employees and patients alike.
References
 	Tprestianni. "131 AI Statistics and Trends for 2024." National University, 1 Mar. 2024, nu.edu/blog/ai-statistics-trends/#:~:text=According%20to%20research%20completed%20by,priority%20in%20their%20business%20plans.
 	Rschmelzer. "Top Reasons Why AI Projects Fail." Cognilytica, 26 Dec. 2023, cognilytica.com/top-10-reasons-why-ai-projects-fail/#:~:text=The%20Shocking%20Truth%3A%2070%2D80%25%20of%20AI%20Projects%20Fail!,-Despite%20the%20buzz&text=Not%20surprisingly%2C%20there%20are%20a,ways%20to%20navigate%20these%20challenges.
 	“Tech skills shortage still a major challenge for healthcare industry, finds GlobalDat”; 16 November 2023; globaldata.com/media/pharma/tech-skills-shortage-still-major-challenge-healthcare-industry-finds-globaldata/.
 	Lerner, Michele. “Worried about AI in the workplace? You’re not alone.” American Psychological Association, apa.org/topics/healthy-workplaces/artificial-intelligence-workplace-worry. Accessed 30 July 2024.
 	Kasyanau, Andrei; “Implementing AI In Healthcare Requires Overcoming These Five Challenges”; 16 July 2024; Forbes; forbes.com/councils/forbestechcouncil/2024/07/16/implementing-ai-in-healthcare-requires-overcoming-these-five-challenges/.
 	Thomas, Nick; “AI has a big future for healthcare but only if workers can embrace it: report”; 16 July 2024; Fierce Health; fiercehealthcare.com/ai-and-machine-learning/ai-has-big-future-healthcare-only-if-workers-can-embrace-it-report.
 	Southwick, Ron; “Nearly half of healthcare workers don’t trust their leaders”; 17 January 2024; Chief Healthcare Executivechiefhealthcareexecutive.com/view/nearly-half-of-healthcare-workers-don-t-trust-their-leaders.
 	Andre, Dave; “60+ AI Statistics in Workplace: 2024 Trends and Predictions”; 26 July 2024; All About AI; allaboutai.com/resources/ai-statistics/workplace/.
 	Machuel, Denis; “Why investing in talent can pull us through a polycrisis”; 16 January 2023; World Economic Forum; weforum.org/agenda/2023/01/davos23-invest-in-talent-future-of-work-polycrisis/.
 	Coleman, Jonnathan; “Healthcare Turnover Rates [2024 Update]”; 21 May 2024; Daily Pay; dailypay.com/resource-center/blog/employee-turnover-rates-in-the-healthcare-industry/.
 	Machuel, Denis; “A majority of workers want AI training from their companies. We must empower them”; 23 January 2023; World Economic Forum; weforum.org/agenda/2024/01/ai-training-workforce/.
 	Somers, Meredith; “How generative AI can boost highly skilled workers’ productivity”; 19 October 2023; MIT Management; mitsloan.mit.edu/ideas-made-to-matter/how-generative-ai-can-boost-highly-skilled-workers-productivity.

### Mucosal Integrity Testing for GERD & EoE
Mucosal integrity (MI) is essential for maintaining esophageal health. It refers to the esophageal lining’s ability to act as a critical barrier, preventing harmful substances, such as stomach acid, bile, and pepsin, from penetrating the tissue. A healthy mucosal barrier in the esophagus neutralizes harmful agents. However, when the mucosal barrier is compromised, these substances can penetrate the tissue, leading to symptoms such as heartburn and chest pain. In severe cases, this can lead to esophageal damage and conditions like esophagitis, Barrett’s esophagus and esophageal cancer.
Assessing mucosal integrity is crucial for diagnosing and managing esophageal disorders. Traditional diagnostic methods, such as pH monitoring and biopsies, are valuable but have limitations. Stand-alone pH monitoring may miss acid reflux events and provides only a limited snapshot in time, while biopsies are invasive and may not capture the full extent of mucosal damage.
How It Works: Mucosal integrity testing (MIT) measures the impedance of esophageal mucosa, which reflects the tissue’s resistance to electrical current. Healthy mucosal tissue exhibits high impedance, indicating a robust barrier. In contrast, compromised tissue shows lower impedance, indicative of dilated intercellular spaces (DIS), which affects paracellular permeability of the esophageal lumen and can be seen histologically in GERD and EoE. (See Fig. 1).
The MI test is conducted with MiVu™ Endo Cap and performed during routine upper endoscopy by attaching a cap with sensors to the distal end of the endoscope, which is connected to the computer-aided analysis system and software. This test provides real-time impedance measurements and can instantly provide a probability of GERD, non-GERD, and EoE. MiVu adds about two minutes to a typical upper endoscopy. (See Fig. 2).
Mucosal Integrity Contour Pattern: Proprietary ZVU® software generates a mucosal integrity contour pattern, visually representing the captured impedance values (see Fig. 3). This pattern provides clinicians with immediate insight into the integrity of the esophageal mucosa, with easy visualization of areas of reduced integrity (see Fig. 3). The contour pattern helps to distinguish between GERD, non-GERD, and EoE, and possibly provides targeted areas for biopsy or follow response to treatment over time.
Clinical Applications and Benefits
 	Information at the time of endoscopy: Immediate information during an endoscopy is limited to what the endoscopist can appreciate visually. They may then miss subtle changes to the esophageal epithelium which do not present as esophagitis. Mucosal integrity testing provides an important additional real-time assessment, detecting early signs of mucosal compromise that other methods overlook. Adding the MI assessment to the physician’s current knowledge of the patient history, symptoms and medication may reduce diagnostic and treatment latency.
“MiVu is an important tool that finally allows us to comprehensively assess for reflux and enables the very early detection of reflux-related effects in the esophagus.” —Amir Masoud, MD. Gastroenterologist, Hartford, Connecticut. 1
 	Differentiating Between GERD and EoE: GERD and EoE are common esophageal disorders that may present with similar symptoms but that require different Mucosal integrity testing helps differentiate these conditions by providing esophageal impedance values over at least 10 cm of the esophagus. EoE, a pan-esophageal condition, often presents longitudinal areas of reduced integrity, while GERD may show more distal areas (closer to the squamocolumnar junction, SCJ) of reduced integrity which improve proximally. Differentiating between these two conditions can help in determining the appropriate treatment strategy.
“There is a lot of symptom overlap between GERD and EoE. Current diagnostic tests for esophageal disorders, which are often inconclusive, make it challenging to provide patients with reliable, timely information that adequately guides the next steps. MiVu’s direct measurement provides accurate, instant data that can immediately direct therapy while helping to reduce the need for unnecessary testing.” —Dr. Michael Vaezi, Professor of Medicine and Otolaryngology at the Vanderbilt University Medical Center in the Division of Gastroenterology, Hepatology and Nutrition. 2
 	Reducing the Need for Prolonged Monitoring and Biopsies: Mucosal integrity testing may reduce the need for prolonged pH monitoring or repeat biopsies by providing real-time data during endoscopy, improving patient comfort, reducing reliance on patient compliance, and streamlining the diagnostic process, allowing for faster decision-making. In those patients with non-erosive disease who had abnormal reflux by wireless pH monitoring, MI values were similar to those with erosive esophagitis. MI was superior in predicting erosive reflux compared to wireless pH monitoring, with a specificity of 95% and positive predictive value of 96% compared to 64% and 40%, respectively 3. MIT accurately predicted EoE during endoscopy with a sensitivity of 100% and a specificity of 96% without the need for 3
 	Long-Term Treatment Management: Mucosal integrity testing has the potential to be valuable for evaluating the efficacy of prescribed In a clinical trial published in the journal Gastroenterology, Fehmi Ates and associates tested the device to assess MI. Subjects with LA Grade C and D esophagitis underwent MIT at both the initial endoscopy and 8 weeks post-PPI treatment. MI values increased and changed from a GERD impedance pattern to a non-GERD impedance pattern.3 By tracking changes in mucosal integrity over time, clinicians may be able to adjust treatment plans to ensure optimal outcomes.
 	Future Directions and Broader Applications: Currently, MiVu from Diversatek Healthcare is the only FDA-cleared mucosal integrity system for sale in the It represents a significant breakthrough in gastroenterology that stands to transform the diagnosis and management of GERD, non-GERD and EoE. As this technology becomes more widely adopted, its applications may extend beyond GERD and EoE to other gastrointestinal disorders. While mucosal integrity testing currently focuses on the esophagus, this technology has the potential to be adapted for use in other parts of the gastrointestinal tract, such as the small bowel and colon, providing valuable insights into conditions like celiac disease and inflammatory bowel disease.
Conclusion
Mucosal integrity testing, uniquely offered with the MiVu system, represents a revolutionary advancement in assessing esophageal health. As more data is published and clinicians recognize the benefits of mucosal integrity testing, it is likely to become an integral part of routine endoscopic evaluations. By providing real-time insights into the health of esophageal mucosa, technologies like MiVu can potentially redefine the standard of care for diagnosing and differentiating GERD and EoE.
This technology provides the endo-scopist with a valuable diagnostic tool, potentially obviating the need for prolonged pH testing and for monitoring esophageal mucosal improvement in response to therapy. As gastroenterology continues to evolve, mucosal integrity testing is poised to improve patient care significantly.
For article references, visit www.endopromag.com.
Figure 2. MiVu EndoCap is mounted onto the working end of the
endoscope and allows for direct visual placement of the sensors on the
esophageal tissue of interest.
Figure 3. ZVU software contour pattern indicative of GERD

### Leaders, Want to Reduce Burnout?
Are medical leaders making their teams feel empowered? Or do they make them feel small, lost and broken? The evidence suggests that medical professionals today are being marginalized, increasingly alienated and made to feel insignificant. Increasingly, large organizations are becoming “systems,” and every day, professionals are faced with difficulties in practicing their professions in authentic ways. This seems to be happening everywhere.
Medical Professionals Don’t Feel Respected by Their Leaders
In San Jose, California, 450 doctors in the Santa Clara County Health System organized and threatened to strike due to worker shortages, outdated and substandard equipment, unsustainable workloads, and a backlog of hundreds of patients waiting for basic services. In October 2022, the group agreed on a contract over untenable working conditions. This contract, which took more than two years to negotiate, focused primarily on professional workload and wellness. It was finally completed just days before the physicians were due to go on strike, which would have jeopardized healthcare services for the people in that region.
In addition, the healthcare professionals cited “dismissiveness” by leadership as a primary reason for their actions. In other words, these professionals did not feel respected, according to Tran Nguyen in the San José Spotlight. In fact, a recent survey of those physicians revealed that two-thirds of them did not plan on staying with the organization. Three out of five of those planning to leave cited not being respected by management as the reason. Another physician leader interviewed by this writer stated: “I am not just a body that can be replaced by another body! We physicians are in a toxic environment today. I have never seen such pathology in the industry that I am seeing today.” But this same physician also provided some optimism: “There is nothing you can get yourself into that you can’t get yourself out of.”
Nurses do not seem to be faring much better. A year ago, nurses in Minnesota were threatening a strike, and those in New York staged and ended a three-day walkout, per the New York Times. The issues? Poor working conditions, staff burnout, cost-cutting by administrators, long patient-wait times, slow service due to staffing shortages, and overworked caregivers.
I spoke to one ICU nurse who said, “I can provide better care when I am not constantly afraid of harming the patient due to being overworked.” Nurses are not feeling respected by their leaders, their patients, or their patients’ family members. They are being taken for granted and no longer feel the joy in their profession. To make matters worse, like the physicians’, nurses’ pay increases have been minimal and are not commensurate with the increases in their workload.
Highly trained nurses, doctors, other healthcare professionals, educators and administrators are leaving their professions in droves. In studies in the U.S. specifically, 50% of workers reported feeling stressed at their jobs on a daily basis, 40% as being worried, 22% sad, and 18% angry, according to Leah Collins on CNBC. Depending on which studies you read, professional burnout is a significant consequence, impairing professional capacity to meet the ever-increasing challenges of daily work, with some professions experiencing 40%-60% burnout rates.
An Opportunity for Outstanding Leaders
All of this is a huge opportunity for leaders who want to encourage outstanding performance. The gift of leadership comes with a responsibility to lift others up—to help them be amazing in their own work. It is not meant to elevate yourself.
One CEO client kept a small box with a dollar sign on it on his desk. He let it be known among his executive staff that any executive that was quoted, interviewed or who got their photo in the local news would have to pay a fine of $100 in the box. His message to the execs was clear and unambiguous: “It is not your job to shine.” In his thinking, it was the leader’s job to make the professionals shine, to help people become wildly successful beyond their own expectations.
Ordinary leadership is when you use your leadership position to serve the company, and the customer. Extraordinary leadership is when you use your leadership position to serve the company, the customer, and the people who follow your leadership—those who do the daily work.
Offer Them a Choice
Of course, we can never know what is best for another person. But as leaders, it is our job to help them achieve great things. To do that, we need to nurture in them a full belief in themselves. By nurturing that belief, we are wielding a significant power to bring about change in others.
Of course, some people are satisfied with the ordinary. Escaping the comfort zone of mediocrity is a huge leadership challenge! The quest for outstanding results often surpasses those who will do nothing to threaten their security and comfort with their current existence.
People have no obligation to live up to our expectations of them. That is their choice. It is the leader’s job to offer choice, and then offer the respect that every human being deserves, regardless of their decision. Sometimes those who choose to be disengaged should find their calling somewhere else, and leaders can help make that happen.
Being Intentional: Making and Keeping Promises
One of the most important results of an outstanding leader is their influence on those who are willing to engage in the work of the organization. Whether that be few or many, it is the most rewarding result of good leadership. Those who live their lives with great intentionality usually leave others behind.
When we move from manager to leader, we are moving from serving the organization to serving the needs of the people in the organization. As we serve and guide them, they will be more intentional in serving the organization and its customers.
To cultivate high levels of engagement and reduce burnout, the best leaders make promises about how they will lead—and then keep those promises. Five promises stand out:
 	I will listen to you, to better understand your wants and needs as a professional. Let’s make sure you have what you need to be successful. Outstanding leaders take the time to know what their professionals need to get things done well.
 	I will always welcome your advice and suggestions and treat your advice respectfully and seriously. If we disagree, I will say so and tell you why. Outstanding leaders understand that professional disagreement is not personal. It is necessary to achieve the best outcomes over time.
 	I will work to make you successful beyond your wildest dreams. Outstanding leaders know that when their professionals are successful, they too are successful.
 	I will make sure you are compensated competitively and respectfully. Outstanding leaders understand that, while competitive compensation is not the most important goal of professionalism, it is absolutely necessary as a sign of respect for what professionals bring to the work of the organization.
 	I will have your back if and when things go south. Outstanding leaders understand that true professionals want to do a great job. Leaders make sure that if things go wrong, unintended events impede results, and things don’t turn out as planned, the focus is on the process glitches, and not on blame and shame. They know that blame and shame are toxic to an engaged professional culture.
As a leader, you have significant power to lift people up, change the lives of those you lead, and nurture that intentionality. But you can only build teams of outstanding performing people if you first focus on becoming intentional yourself about how you lead.
Who are you lifting up today? Be intentional about it!
For article references, visit www.endopromag.com.

### AfterCare: Rattle When You Walk? (Part 2)
In my last installment, I discussed supplements for general health and joint and muscle relief, as I followed my mother’s alchemist footsteps in seeking supplements to improve my health, and followed my own scientific training to review and potentially discard supplements that no longer had sufficient science to support their use.
How to choose what supplements to take? A refresher:
 	needs to have peer-reviewed and published clinical data
 	add only one new supplement at a time
 	reassess in 1 month/bottle (If questionable improvement in symptoms, stop the supplement and see if symptoms If asymptomatic, are there possible lab tests to verify improvement?)
 	review your supplements every six months—science changes!
Here is a list of what I choose to take daily, minus the prescriptions:
Womens MVI Vitafusion 2 qD
Biotin 5000 mcg qD pending
Turmeric, 2 grams qD–yes!
Omega 3, 2000 mg (vegan, not fish oil–pending)
CoQ10, 100 mg qD–yes!
Amla fruit, 1 gram qD–pending
B12, 1000 mcg qD–yes!
Magnesium oxide, 300 mg qD–yes!
Vitamin D3 5000 iu gelcap qD–discussion with internist, possible discontinuation and recheck levels Boswellia serrata, 500 mg qD–yes!
Quercetin, 500 mg with bromelain, 100 mg qD–pending
Last issue I decided to stop daily multivitamins, biotin, and probably vitamin D, despite a confirmed deficiency. So let’s continue my semiannual, objective, virtual hike up my pill mountain together.
“It’s easy to tell the difference between good cholesterol and bad cholesterol. Bad cholesterol has an evil laugh.” – Randy Glasbergen (cartoonist)
Elevated Cholesterol
My family suffers from cardiovascular disease: heart attacks both fatal and non-fatal in my father, maternal grandfather and maternal uncle, stroke for my maternal grandmother. I had been reluctant to start a statin for years due to episodes of “big kahuna” statin myositis in both Dad and me. Thank goodness for my patient and persistent internist getting me started on subtherapeutic statin, which I am finding tolerable. Next step may be a therapeutic dosage!
While reviewing for this installment, my eyes happened upon my Pravastatin bottle ... with NIGHTTIME dosing instructions. Silly me, I’d been taking the Pravastatin in the morning with my pill pile. However, upon research, I discovered Pravastatin (and about half of the statins) are “short acting,” with Pravastatin only sticking around in the bloodstream for about 8 hours. As the liver predominantly produces cholesterol at night (duh), the Pravastatin lowers cholesterol better when it is available in the liver during those hours to block cholesterol synthesis. A learning experience, and now I will take my Pravastatin with bedtime dosing for improved control. Other bedtime, short half-life statins include Simvastatin and Fluvastatin. Check with your doctor or pharmacist if you, too, haven’t been reading your own labels!
Back to cholesterol elevations. The newest information (from this fall’s International Conference on Nutrition in Medicine) suggests that your annual or semiannual lipid panel levels don’t do much to prevent heart attacks or strokes, as the lipids seem to modulate/change between the several forms. However, medicine now suggests that everyone have a once-per-lifetime test for Lp(a) (say “Lipoprotein little a” or “LP little a” to sound informed), a new independent marker for cardiovascular disease. From what I understand, the protein Lp(a) wraps around the LDL cholesterol, and the combination is sticky, so it firmly attaches to the artery endothelium, promoting
atherosclerotic plaques.
Why would your body make this deadly stuff? Researchers hypothesize that it may have provided a survival advantage by aiding in wound healing and reducing bleeding, particularly in childbirth. It affects 1 in 5 people and is more common in blacks of African descent and South Asians. It is genetic, so a positive test should lead to your relatives being tested as well. Researchers are still trying to figure out the best way to manage an elevated Lp(a); review the ACC guidelines for more1 if you or yours test positive.
However, it seems clear that rather than a lipid panel, a panel that contains APO-B corresponds better to the levels of damaging LDL particles in the bloodstream. Dr. Thomas Dayspring, the reigning king of lipids, suggests that an APO-B level yields better information about cardiovascular risks, especially if you’re being currently treated with statins—I encourage you to view some of the numerous videos of Dayspring’s (charming, and discordant with my previous cholesterol knowledge education), and unravel the cholesterol knot for yourself. The lipid story has changed yet again.2 As Dr. Dayspring says, “The graveyard is full of people with high HDL cholesterol.”
“What do you call a fat alien? An extra-cholesterol.” – Unknown
So other than Pravastatin, what am I doing for my cholesterol numbers—or, being modern, my elevated APO-B levels?
DHA and EPA, the active components in fish oil, are in retreat; current studies do not support a drop in cardiovascular events with high blood levels of Omega 3 fatty acids.3 When I complete my current bottle of algae-derived “fish” oil (in my quest to be a good vegan, I bought this expensive peppermint scented stuff), I’ll stop this supplement.
Other options include green tea, ground flaxseed, garlic and niacin. Meh—none as strong as the statin I’m on, although I’ll continue to enjoy my culinary garlic and my hot jasmine green tea.
“Healthy Diet Day 1: I have removed all the bad food from the house. It was delicious.” – Unknown
I’ll also redouble my efforts at being a clean-eating vegan for the inherent cholesterol, diabetes and weight benefits.4 In the recent meta-analysis of thirty RCTs, the vegan diet outperformed the omnivores as expected, with reduced total cholesterol, low-density lipoprotein cholesterol, and apolipoprotein B levels with “mean differences of −0.34 mmol/L (95% confidence interval, −0.44, −0.23; P= 1 × 10−9), −0.30 mmol/L (−0.40, −0.19; P = 4 × 10−8), and −12.92 mg/dL (−22.63, −3.20; P = 0.01), respectively.” I’ll also continue the exercise, exercise, exercise—resistance, balance, flexibility and core work.
This will help both my cholesterol management and my T2D.5 Resistance training may help management of Type 2 diabetes by “decreasing visceral fat, reducing HbA1c, increasing the density of glucose transporter type 4, and improving insulin sensitivity. Resistance training may enhance cardiovascular health by reducing resting blood pressure, decreasing low-density lipoprotein cholesterol and triglycerides, and increasing high-density lipoprotein cholesterol.”
“Please don’t sugarcoat it; I’m diabetic.” ~ Unknown
 Type 2 Diabetes
A good time to segue to T2D—as both my chosen diet and my exercise plan support the management. I am also on the middle dose of Ozempic, as Metformin had little effect.
But what other supplements have I experimented with?
Amla fruit6 improves both fasting glucose and postprandial glucose, as well as lowering total lipids and cholesterol. Double the dose I chose to take also lowers LDL and raises HDL cholesterol. I’ll keep this antioxidant but not escalate the dosage.
Quercetin7,8 mimics metformin in its antidiabetic effects, and additionally carries anti-oxidative, anti-inflammatory, antiproliferative, anticarcinogenic and antiviral properties. It is considered helpful in combatting age-related disease—so I fit that description8 (insert sad face here). The bromelain9 that comes with it is generally useful as well, with anti-inflammatory, antidiabetic, anticancer, and antirheumatic properties—so I’ll keep this combo for general health.
Thanks for riding along for my review of supplements. I’m pleased to have discarded four, leaving me with seven with decent published evidence to support continuing their use. I’ve added the exercise and the vegan diet, as I believe that they should be prescriptive for good health.
Final tally:
Exercise Vegan diet
Amla fruit, 1 gram qD
B12, 1000 mcg qD
Boswellia serrata, 500 mg qD
CoQ10, 100 mg qD
Magnesium oxide, 300 mg qD
Quercetin, 500 mg with bromelain, 100 mg qD
Turmeric, 2 grams qD
For article references, visit www.endopromag.com.

### Flexible Endoscopes
Preventable GI endoscope damage can primarily be avoided by following proper handling practices during procedures; thorough cleaning and disinfection protocols after each use; scrutinizing the endoscope for any defects, and storing it correctly to prevent physical damage, including avoiding excessive bending or twisting of the insertion tube; using appropriate cleaning accessories; not forcing instruments through channels; performing leak tests regularly; and storing the scope in a designated, well-ventilated cabinet; all while adhering to the manufacturer’s instructions for use.
It’s essential to take human factors into account. A study of the interaction between people and the systems they use, human factors focuses on the interplay between individuals and the systems they engage with. By integrating human factors into the design of medical devices, manufacturers can create products that are more intuitive for users and more manageable for reprocessing staff to clean and inspect.
During procedures, we want to practice gentle manipulation by avoiding excessive force when bending or twisting the scope, especially in tight areas. It’s crucial to ensure that accessories are compatible with the scope and used correctly, avoiding forceful insertion. Additionally, utilizing bite blocks when necessary can help prevent damage to the bending section. We should also minimize loops to prevent them from forming in the scope before passing accessories through the channel.
Immediate pre-cleaning after a procedure is vital to prevent debris buildup, biofilm and potential damage to the endoscope. This process involves thorough cleaning of the endoscope with enzymatic detergent right after use. It’s essential to flush all channels thoroughly with water and air, using the appropriate brushes for each channel. A leak test should be performed before and after cleaning to identify potential damage to the scope.
Adhering to the manufacturer’s guidelines for cleaning agents, disinfection methods and soaking times is crucial. This adherence ensures the longevity of the equipment and provides peace of mind.
Endoscopes require a dedicated storage cabinet. It’s essential to hang and dry the endoscope within a designated cabinet properly, or if using horizontal storage, following the operations manual. Avoid tightly coiling the endoscope during storage, as this can damage the bending section. Additionally, regular inspections should be conducted before each use to check for signs of wear or damage, which is vital for ensuring the safety and functionality of the endoscope.
Potential consequences of improper endoscope handling include:
 	Channel damage: When the channels of an endoscope suffer tears or develop leaks due to mishandling, it can create pathways for fluid and microorganisms to enter. This compromises the device’s integrity and poses a severe risk of contamination, leading to potential malfunctions that can jeopardize patient safety.
 	Bending section damage: An endoscope is designed to navigate the complex contours of the human body. However, excessive bending or twisting of the bending section can severely disrupt its maneuverability, making it difficult to access targeted areas effectively. This damage reduces the scope’s performance during procedures and may necessitate costly repairs or
 	Component failure: The endoscope consists of various intricate components, including the light source and control unit. If these parts become damaged due to improper handling, it can lead to operational A malfunctioning endoscope may fail to provide adequate visualization during procedures, complicating diagnoses or treatments.
 	Increased risk of infection: Proper cleaning and sterilization of endoscopes are crucial to patient safety. When instruments are not cleaned correctly, contaminants can remain on the surface. This residual contamination heightens the risk of transmitting harmful pathogens to patients, potentially leading to serious infections and complications post-procedure.
Human factors play a critical role in the endoscope reprocessing process, significantly influencing patient safety. Various elements can either enhance or compromise these practices.
To mitigate the risk of contamination and infection, quality assurance strategies should include comprehensive training programs aimed at identifying deficiencies. Staff members often lack extensive training on the best practices and techniques required for effective endoscope reprocessing, which can create gaps in their understanding. Additionally, there is a lack of awareness regarding the unique cleaning needs of different types of endoscopes. These needs can vary based on design and intended use.
Time constraints can pressure staff to rush through cleaning protocols, increasing the likelihood that critical steps necessary for proper sanitization may be overlooked. Established cleaning protocols may not be followed with the required precision, leading to variations in effectiveness. Furthermore, improper selection and use of cleaning brushes can damage the delicate channels of the endoscope, jeopardizing its functionality. While hand hygiene is crucial, lapses can still occur, risking contamination. Inadequate inspection of endoscopes for visible debris or contamination can allow harmful pathogens to remain unnoticed. Staff may also fail to flush all channels with suitable cleaning solutions, which is critical for effective sterilization.
The reprocessing area can present many distractions, such as conversations or equipment noises, detracting staff from the concentration necessary for thorough cleaning. Insufficient lighting can hinder a technician’s ability to inspect and clean endoscopes effectively, potentially leading to oversights. Additionally, high workloads and fatigue can impair focus, increasing the risk of mistakes during cleaning. Ineffective communication with staff members may also result in misunderstandings and errors in the cleaning workflow.
The consequences of ignoring human factors can be severe. Inadequate cleaning practices can leave residual bacteria or pathogens on endoscopes, posing a tremendous risk of infection for subsequent patients. Improper handling and cleaning techniques can damage sensitive channels, ultimately impacting the performance and safety of the endoscope. Not adhering to recommended procedures may lead to incomplete reprocessing, rendering endoscopes unsafe for clinical use and endangering patient health.
To address these challenges, institutions should establish regular training sessions for all personnel involved in endoscope reprocessing, emphasizing proper techniques and quality control measures. Clear and detailed cleaning and handling protocols must be developed to ensure that all staff members have consistent and comprehensive guidelines for their reprocessing tasks. Regular audits and inspections are essential to identify potential issues and facilitate timely corrections and improvements.
Ensuring an adequate number of staff members to complete cleaning procedures thoroughly can help prevent rushed work and promote adherence to best practices. Create enough space to prevent endoscopes and equipment from swinging or hitting walls, beds or other equipment in the room. Additionally, utilizing cleaning equipment with ergonomic considerations can reduce the likelihood of errors and enhance the efficiency of reprocessing efforts.
By thoroughly addressing these human factors and implementing solid strategies, healthcare facilities can significantly improve the safety and effectiveness of endoscope reprocessing, better protecting patients from infections, and ensuring the proper function of this vital medical equipment.

### Joint Venture, Joint Pride
The endoscopy department at Bridgewater Ambulatory Surgery Center, Bridgewater, New Jersey, operates within a multispecialty free-standing ambulatory surgery center, which is a joint venture between Hunterdon and Atlantic Health Systems. The team prides itself on its diverse and skilled professionals, ensuring top-notch care for patients.
The department performs approximately 2,000 procedures a year via one dedicated endoscopy room, and there are plans to expand by adding another endoscopy room.
“We are well-equipped with three bays each for endoscopy pre-procedure and recovery, ensuring efficient patient flow and care,” explained Jeanette Cowen, MSN, RN, CNOR.
The department primarily focuses on diagnostic procedures, including esophagogastroduodenoscopies (EGDs) and colonoscopies— crucial for diagnosing and managing various gastrointestinal conditions.
Dr. Sandeep Bhargava, gastroenterologist, said, “I like to bring my patients to this center because it is a state-of-the-art facility that provides hospital level care in an outpatient setting. My patients like the quicker throughput of an ambulatory center. The nurses are hospital trained, and that gives a high level of skill that you don’t see in many outpatient facilities. The anesthesia team is also great.”
The team comprises registered nurses (RNs), surgical technicians, sterile processing technicians, gastroenterologists and anesthesiologists. Three RNs are dedicated specifically for endoscopy: Joanne Colangelo, Cathleene Francis (CGRN), and Lorraine Casterline. The operating room RNs (Leona Kardux, Geraldine Martino, Candace Routel, Arielle Doering, and Jeanette Cowen) and surgical technicians (Shondra McGill and Tiffany Duperrier) are cross-trained and proficient in endoscopy procedures.
Joanne Colangelo, BSN, RN, said, “What I love about the endo team is the synergy we have. Lorraine, Cathy, and I trained together and have been working together for many years. We don’t even need to talk; we know what the others need, and we just do [it]. This is the best team right now that we have had since the center opened in 2018.”
An essential part of any department’s efficiency and infection prevention are the scope processing technicians, and Bridgewater is no different, employing techs Chris Lee, Aliyah Amponsah, and Erika Alvarado to keep scopes safe and patient-ready. Lee said, “This job is not ‘work’ for me. I truly enjoy what I do. I had a terrible experience of having a postop infection many years ago, and my goal is to never let an infection happen to any patient. I know I probably create extra work for myself, but I double and triple check processes to make sure that every scope is free from contamination.”
Anesthesiologists from Hunterdon Health play a crucial role in providing moderate sedation for patients. “The pre-procedure and post-procedure RNs—Vanessa Conyers, Ashley Ridgeway, Caroline Zajac, Daria VanDoren, and Bridget Zinenko—are recognized for their exceptional skill and bedside manner. Their expertise is highly valued by both our patients and physicians, who appreciate the center’s efficiency and patient care standards,” Cowen said.
Daria Van Doren, BSN, RN, CCRN, pre- and post-procedure RN, said, “Patients say they were so nervous before the procedure, but everyone made them feel relaxed, so it ended up being a positive experience.”
The admitting team includes Tracey Timmons, Diana Kasper, Kriya Patel and Janette Arama. Diana Kasper, CST, scheduling/ billing/registration representative, said she enjoys interacting with patients. “They are always so pleasant during the check-in process, in spite of the fact that many have been through the GI prep process.”
The leadership team includes Paula Zuckerman, the executive director; Imily Gonzales, the director of nursing; Dr. Brian Sperling, the medical director; and Dr. Michael Lapicki, the anesthesia director. “Together,” Cowen said, “they guide our center toward excellence, making it a preferred facility for both our gastroenterologists and patients.”
The backbone of the team’s excellence is its years of clinical experience. “Seasoned members with extensive endoscopy experience are always eager to share their knowledge and insights with newer colleagues, fostering a culture of continuous learning and improvement,” Cowen said. “We stay at the forefront of advancements in our field by keeping up with the latest equipment and techniques. Belonging to professional organizations, attending conferences, and staying updated through journals such as EndoPro Magazine and the journal of the Society of Gastroenterology Nurses and Associates, contributes significantly to our expertise.
“Teamwork is essential, and we believe in pitching in to help one another with any task that ensures the day runs smoothly,” Cowen added. “Accurate record-keeping and high patient satisfaction are vital benchmarks of our success, so we diligently monitor these goals. Effective communication is at the heart of our operations. In the procedure room, team members promptly alert others to any malfunctions, and we collaboratively troubleshoot and resolve issues. When patient concerns arise, each team member knows their role and works cohesively to ensure the best possible outcomes for our patients. Continuously monitoring and maintaining the highest standards of patient safety and infection control is paramount. This requires ongoing training, vigilance, and adherence to best practices to prevent any lapses that could affect patient outcomes.”
The team bonds through monthly and as-needed staff meetings, where team members are encouraged to openly discuss concerns. “This practice not only keeps everyone on the same page, but also strengthens our unity,” Cowen said. Colleagues get to know each other in the staff lounge, where folks unwind, share stories and stay updated on each other’s lives. The team also enjoys lunches together.
Challenges are a part of any endo team’s workday, and Bridgewater is not exempt. Cowen said the team has faced staffing shortages. But, she said, the regular staff “rose to the occasion, rearranging their schedules or working extra hours to ensure continuity of care. In addition, we are fortunate to have access to a pool of excellent agency staff who assist us on a day-to-day basis, ensuring that patient care remains unaffected.”
Shondra McGill, CST, CASSPT, CSPM, AST fellow, stated, “I like the pace of the endoscopy cases. I also like being involved in promoting the health and well-being of patients. We work as a team in endoscopy, and everyone feels appreciated for the work they do.”
Other challenges endoscopy teams experience include regulatory compliance, patient volume and scheduling, technology and equipment maintenance, insurance and reimbursement, and patient safety and infection control. Cathy Francis, RN, CGRN, said, “We have put processes in place to go above and beyond what was required, long before they became a standard of practice.” The team’s safeguards and best practices include:
 	Effective “Clear and open communication is the cornerstone of our success. By ensuring that all team members are informed and engaged, we can efficiently address any issues and work collaboratively towards common goals.”
 	Adherence to guidelines and best practices. “Following established guidelines and recommended practices ensures consistency and high standards of care. Our team rigorously adheres to these protocols to maintain the highest level of patient safety and service quality.”
 	Shared goals and teamwork. “We believe that working together with shared goals is crucial for Every team member understands their role and how their efforts contribute to the overall objectives. This collective approach ensures that we all work for each other and, most importantly, for the patient.”
 	Philosophy of patient-centered “Our philosophy revolves around centering our efforts on the patient through teamwork. We take the concept of patient-centered care and extend it to encompass the entire team, renaming it to be ‘Teamwork: Centering on the Patient.’ This approach ensures that every decision and action is made with the patient’s best interest in mind.”
By integrating these principles into its daily operations, the team creates a supportive, efficient, and high-performing environment that benefits team members and patients.
Cowen summed up the team, saying, “Despite challenges, our team remains committed to delivering the highest quality of care. By leveraging our collective experience, maintaining open lines of communication, and fostering a supportive work environment, we continue to overcome obstacles and provide exceptional service to our patients.”

### A Swedish Idea That Isn’t IKEA
Single-use plastic. It’s everywhere.
Medical supplies like gloves, medical equipment, and a vast number of other disposable supplies are a huge environmental issue worldwide. We have used them extensively in the health sector and we don't have a way to recycle them. Efforts are underway, however. Researchers at Sweden's Chalmers University of Technology, for example, are detailing how certain medical waste can be recycled successfully and effectively. The method: Plastic is melted and broken down into chemical building blocks, which become raw material to make new plastic.
Everyone involved in healthcare knows how much plastic waste there is. Sometimes it's burned – and that comes with its issues – and all too often, it's thrown away in a landfill. As stated in a Chalmers press release, "Disposable healthcare products typically include multiple forms of plastic that cannot be recycled using current technology. On top of that, the products must be treated as contaminated once used, [so] the products need to be handled in a way that avoids the risks of transmitting potentially infectious germs.". In the case of single-use healthcare products, it is also impossible to utilize recycled plastic, as the purity and quality requirements are too great for such material which is destined for use in the medical field."
Chalmers scientists say that the problems can be resolved using a process they created known as "thermochemical recycling." The process uses a technique known as "steam cracking," where waste is disintegrated by combining it with sand at around 1,472 degrees Fahrenheit. The plastic molecules are turned into gas and can be recycled to make new plastic. The process is more of a "thermal sledgehammer," says Martin Seemann, associate professor at Chalmers' Division of Energy Technology. The "thermal sledgehammer" doesn't merely crush the molecules: It kills bacteria and other microorganisms as well. "What remains are various forms of carbon and hydrocarbon compounds," Seemann said. "These can then be processed and utilized in the petrochemical industry, to substitute fossil materials that are already being used in production."
The scientists have already tested products like gloves and face masks. They also prepared a blend that simulates common hospital waste of approximately 10 various plastic materials, as well as cellulose, the news release states. The outcomes were promising in every project.
One of the projects was conducted by Judith González-Arias, who is currently at the University of Seville in Spain. What is so exciting about this technology is that it can deal with the environmental issues that we relate to medical disposables," González-Arias said. "Thermochemical recycling not only solves the issue that medical waste is not recycled today, but also allows for the recovery of precious carbon atoms.". This is entirely consistent with the principles of the circular economy and represents a sustainable answer to the pressing problem of the management of medical waste."
There's more to it than that, though, so we'll be revisiting this thrilling subject in our May editor's letter (the April editor's letter will be taken up with FODMAPs' digestion-friendly diet). Until then, though, let's do what we can to limit single-use plastics at home and the workplace, even if we don't have a thermal sledgehammer.
 

### A Solution for Maximizing Department Space
The PureSteel Mobile Soaking Station from PureProcessing delivers dedicated spaces for soaking and cleaning surgical instruments and endoscopes, the company reports. The Mobile Soaking Station features horizontally soaking robotics, endoscopes, larger orthopedic instruments or surgical instruments with longer soak times, as stipulated in IFU.
The Mobile Soaking Station is built on casters for mobile use and includes an organizational back wall to organize cleaning and soaking accessories, without taking up additional counter space. Mobile Soaking Stations can be outfitted with electrical, a PureSoak™ Waterproof Timer , PureChannel™ Flush Touchless Auto Dispenser, and FlexiPump™ Independent Flushing System to create secondary reprocessing sink.
The Mobile Soaking Station can be purchased with a faucet and hard-plumbed, when needed.
Features to help your SPD and/or GI department
 	Soaking capacity: Perfect for a 30-minute robotic soak per IFU, or delayed reprocessing for flexible endoscopes
 	Capacity: Create extra sink spaces for reprocessing, or establish dedicated areas for specific surgical instruments
 	Size: 30”x18” basin perfectly fits robotics, orthopedic sets and longer instrumentation
 	Full-loaded station: Included organizational back wall pegboard keeps tools close at hand without using additional countertop space.
Technical Specifications
 	34"x22"
To request more information, click here.

### Cybersecurity
What's the distinction between an endoscopy device and a hacked ATM? To a hacker, not much.Endoscopic technology has evolved over the past decade, adding artificial intelligence to its diagnostic function and increasingly advanced tools to expand its treatment value. But as with any networked medical device, endoscopes expose hospitals and medical facilities to cyberattacks.In 2023 alone, healthcare paid an average of $10.93 million per breach—almost double the cost to the second-place runner-up, the finance industry. It has been so severe that the U.S. Department of Health and Human Services (HHS) has come up with a plan to protect against cyberattacks and ransomware, with the threat of legislation and higher regulations on the horizon.Although the problem is not straightforward, hospitals and medical facilities can do fairly straightforward things to protect their information. In fact, the secret to security health is not significantly different from the recommendations physicians make regarding physical health: Get frequent checkups, stay current with antivirus programs and receive treatment from experienced professionals.Stay Off the InternetMedical equipment must not be connected to the internet. Anything that is connected to the internet is an easy target for hacking. According to a survey conducted in 2019, 80% of hospitals have been affected by a cyberattack targeting Internet of Things (IoT) devices.These vulnerabilities were highlighted by the FBI as particular security threats. And in the majority of these instances, such threats are superfluous: Medical devices depending on AI and machine learning are not necessarily required to be hooked to the internet to take advantage of the humongous warehouses of data driving AI capabilities.Air GapBesides being unsafe, the use of medical devices on the internet is superfluous. A network that is not linked to any external network—like the internet—is referred to as an "air-gapped" network. A scope and a hospital's EMR can communicate by means of secured, air-gapped networks. Bridging such networks can be done with the help of dual-homed machines that have the ability to link to both the air-gapped and internet-linked networks. Installing these relationships requires finesse and technical knowledge: an initial investment that, in the event of a potential $11 million breach, hospitals might deem well worth the expenditure (stay tuned for that explanation).Update Older Operating SystemsLegacy operating systems such as Windows 95 and Windows 7, 8, 10 (secutiry updates have a cut-off after October 14, 2025) which are or will no longer be supported might not have the security patches required to keep them safe from attack. If the legacy system is not supported, and a hospital's equipment is not on an air-gapped network, then they could be susceptible to attack.During a 2022 declaration, the FBI cautioned of unpatched and old medical device and legacy systems' cybersecurity vulnerabilities, describing the fact that "40% of medical devices reaching the end-of-life point provide little or no security upgrades or patches that are able to repel attack.".Protect Against VirusesAntivirus software frequently is not installed on medical equipment because it conflicts with medical software or vendor policies. In some instances, the machines themselves are underpowered, having insufficient memory or CPU power to execute antivirus software and the clinical application. In other instances, hospitals are reluctant to install antivirus software for fear device manufacturers will no longer support equipment. The end result is an unguarded device that can be easily penetrated.Similar to physical viruses, computer viruses have caused actual deaths: An Alabama hospital paid a settlement in 2021 on a lawsuit over the death of a newborn who experienced birth complications during a ransomware attack at the hospital that kept doctors from getting timely access to the baby's fetal monitoring results.Check CredentialsHospitals often give full administrative rights to devices without understanding the implications. Once a hacker gets into an endoscope's software, he or she has the same level of trust that the device has. So in an endoscope that had admin access given, that hacker would be able to use the device to achieve full access to a hospital's medical records. It places patients—and the hospital—in great jeopardy.To minimize the damage in case of a security breach, low-power accounts must be employed on all devices. Regular network scans must also be performed to detect unauthorized devices, administrative access and suspicious software installations.Break It UpMicro-segmentation—a network security technique that breaks a network down into extremely small, isolated segments—can also safeguard against a malicious actor taking complete control of a hospital's network via a breach in one device. Similar to air-gapped networks, this requires expertise and effort to establish and maintain but can be well worth the cost.Also known as a "black box" solution, micro-segmentation involves the mapping of data and workflows and introduces friction into the daily operation of a hospital or medical center. But the payoff is in severely curtailing any breach.Keep IT LocalOffshoring IT support may save cost, but it can significantly diminish security. Without a professional staff to monitor your network and devices, scan for problems and defend security, hospitals and medical facilities open themselves up to invasion.At least 29% of data breaches are caused by third parties—with three-quarters of those caused by vendors who offer technical services like software, IT products and related services. Having your IT staff local—or better yet, in-house—allows you to maintain control of visibility, simplify communication and ensure that the entire team you employ is operating under the same regulatory environment.Don't Rely on InsuranceAs a stopgap measure to funding costly IT departments, some hospitals buy cyber insurance. This can be short-sighted at best and useless at worst. Insurance firms only pay out if a company uses normal and sufficient care to protect against threat. By abandoning—or outsourcing—their IT departments and wishing for the best, hospitals show the very opposite: They haven't exercised sufficient care to protect against a cyberattack. Consequently, the hospitals are left with an expensive lapse that will not be paid for by their insurance providers. Don't Skip the Small StuffPassword-protect your devices. Include firewalls, patch management and access controls for all networked devices. Yes,these actions introduce a level of friction into a process, but the slight inconvenience is more than worth it. Passwords are one of the most effective means of controlling data flows and keeping sensitive information from unauthorized access.That being said, don't forget to replace default passwords that can be included with your device: In February 2023, a maker of infusion pumps issued an alert that one of their products had a password flaw that could potentially open up access to personal data.Do a SweepWhen a person departs your organization, ensure they have no access to your network anymore.Checking login credentials and access controls for endoscopy machines—and all machines—will ensure they are securely locked down. This will prevent unauthorized use and ensure confidentiality and integrity of your data. We refer to credentials for individuals no longer with the organization as "zombie accounts," and like zombies from horror movies, they leave hospitals open to attack. In other instances, the "zombies" are actively working against the law. In others, they may be unaware that they still have access to their former accounts. So, if their personal accounts have been compromised, they will not realize they should inform their old employers of the potential for a cyberattack. Key TakeawaysIn 2017, Mexican criminals notoriously used endoscopes by way of the cash exit slots in ATMs to control sensors in the dispenser and replicate physical verification that prompted the ATM to spew forth cash like a slot machine in Vegas that just hit the jackpot.But the bad actors do not need to hold actual endoscopes in their hands to employ these and other medical devices to gain access to lucrative personal data or hold hospitals hostage. To secure healthcare data, hospitals and medical facilities must look at safety breaches when they buy or upgrade new equipment and take some serious steps to ensure their cybersecurity.Keep medical devices offline.Use air-gapped networks for medical devices.Update older operating systems and use patches for older devices.Protect against viruses.Prevent granting administrative rights to devices.Use micro-segmentation to manage network traffic granularly.Have a dedicated IT security department and networking team with the required skills to configure and secure networks appropriately.Password-protect all medical devices.Sweep regularly for unauthorized access.Similarly, as physicians instruct patients to keep their body health in check, the healthcare sector needs to undergo periodic checkups, keep abreast of antivirus practices and take advice from cybersecurity professionals to ensure their cybersecurity health is in top condition.

### Medical Data Breach of a Different Sort:
Unfortunately, odds are good you’ve received notice at some point in your life about your data being leaked in one capacity or another—usually through someone hacking into a business database. Sometimes, the breach involves a healthcare organization, such as the massive 2016 hack into Banner Health that exposed the protected health information of nearly 3 million people. A recent big data breach impacted healthcare differently: The attack was on medical professionals. Cybernews research team reports that a huge data breach at a Florida-based recruitment firm impacted over 14,000 hospitals and medical professionals. In June 2024, the researchers found "an open web directory hosting a database backup belonging to MNA Healthcare.". This American firm is reputed for providing staffing services for healthcare professionals and placing them in the best healthcare organizations." The magnitude of the leak is enormous. Cybernews broke the news that the compromised data comprises:Information from 11,000 hospitals14,000 physicians' accounts37,000 potential leads11,000 job applicationsThe compromised sensitive information contained names, addresses, phone numbers, email addresses, birth dates, work history, jobs that MNA Healthcare had assigned, contacts with MNA Healthcare agents, encrypted Social Security numbers (SSNs). Financial fraud and identity theft are potential criminal intent. The compromised information also puts victims at risk for phishing attacks and other scams. The stolen social security numbers facilitate the ease with which criminals can obtain credit cards, get loans, or act as a gateway to gathering additional information. There were various issues with data storage, Aras Nazarovas, a Cybernews security researcher, said. "Data leak raises additional concerns about the security of the company's infrastructure, as the database backup for their platform was stored inappropriately, and a configuration file with the key most likely used to decrypt SSNs." The investigation continues. If you have been a victim of identity theft or data leak, report it to your local police immediately, and online at identitytheft.gov. This website can assist you in recovering from the attack and includes information so you can guard against future assaults. Further, you should contact each of the three credit reporting companies—Equifax, Experian, and Transunion—and place a credit freeze on your accounts. A data breach is no joke, but through assistance from local and national law enforcement, you can regain your possessions—and your sense of well-being.

### Hospital Hackings Surge
The same technology that makes it easy for patients to order prescription refills, see test results and schedule appointments with doctors has also made it simple for hackers to launch debilitating cyberattacks on hospitals and healthcare systems, and experts say there's no end in sight."These cyberattacks against our hospital systems here and overseas only underscore the very pressing need for better cybersecurity within the healthcare industry as a whole," stated Steven McKeon, cybersecurity specialist and MacguyverTech and MacNerd founder.In 2023, the United States' healthcare and public health was the most targeted by ransomware attackers, a new FBI report revealed, well ahead of other essential services such as transportation and energy.As analysts point out, cybercriminals make these highly complex and harmful ransomware attacks to encrypt vital computer systems and pilfer data as a tool for extortion.Why is healthcare such an easy target? Perhaps it is its old technology."Our company's experience and its growing need to repair outdated technology that is in some instances more than a decade old is very alarming," McKeon stated. "With one in three Americans affected by data breaches, upgrading these systems and strengthening cybersecurity safeguards are crucial to safeguarding patient information and providing safety and continuity of care."The healthcare system requires assistance in the form of more federal funding and enforcement of mandated cybersecurity best practices and improvements. With growing cyber threats, McKeon feels securing and informing others on security has never been more urgent.Eager, collective public health efforts must become a prime international priority with cooperation among governments and the health industry sectors imperative in confronting threats to these networks and protecting such systems for the long term," said McKeon. In his over 25 years experience within the technological domain, he maintains that an expansion of best-practice-based cybersecurity through multicased security slows hackers by taking much more effort in order to invade defenses.Reference:U.S. Federal Bureau of Investigation. (2023). Internet Crime Report. https://www.ic3.gov/AnnualReport/Reports/2023_ic3report.pdf

### Food Is Medicine
By the Food Research & Action CenterThe Food Research & Action Center (FRAC) is a nonprofit that improves the nutrition, health, and well-being of people struggling against poverty-related hunger in the United States through advocacy and partnerships, and by advancing bold and equitable policy solutions.Healthcare practitioners don’t often equate endoscopy with social services. However, any medical professional— particularly those in gastroenterology—has unique access to information about whether a person is receiving proper nutrition. Does your office screen for food insecurity in your patients? If not, it may be a good idea to start.Across the United States, healthcare providers are now screening millions of patients for food insecurity, spurred in part by several large-scale national quality and standards-setting initiatives requiring screenings for health-related social needs (HRSN), including food insecurity. For example, given new Centers for Medicare & Medicaid Services (CMS) requirements, hospitals will be required to screen patients for food insecurity and refer patients to appropriate resources to improve patient well-being and prevent readmission related to a social determinant of health.Many healthcare providers are addressing food insecurity by connecting patients to the Supplemental Nutrition Assistance Program (SNAP), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), school meals, and other federal nutrition programs, which are enormously well-studied, with documented benefits to health, nutrition and well-being. This should serve as the foundational intervention to address food insecurity.Referring PatientsThe primary intervention for healthcare systems to address health-related food insecurity and improve patient nutrition and health should be ensuring eligible patients are accessing the federal nutrition programs. These include SNAP, WIC, after-school and summer meal programs, childcare meals, school breakfast and lunch, and congregate and home-delivered meals for older adults.These federal nutrition programs are available nationwide, come with billions of dollars in federal funding, and have reams of research attesting to their efficacy in improving nutrition, health, and well-being of participants. Connecting patients to federal nutrition programs such as SNAP and WIC would also result in an overall decrease in healthcare costs and readmissions and provide patients with a better quality of life.Using healthcare settings to connect patients to SNAP and WIC has become a national priority. The efficacy of these efforts is highlighted in the American Academy of Pediatrics’ 2015 “Promoting Food Security for All Children” policy statement (reaffirmed in 2021) that extols the importance of connecting children and their families to SNAP, WIC, school meals and other federal nutrition programs.Additionally, the 2022 White House National Strategy on Hunger, Nutrition, and Health encourages the healthcare sector to “screen for food insecurity and connect people to the services they need,” including SNAP and WIC. In November 2023, the White House released the first ever U.S. Playbook to Address Social Determinants of Health, which underscores the importance of SNAP and WIC in improving food security and includes commitments from CMS and the U.S. Department of Agriculture (USDA) to use data to bolster enrollment of Medicaid participants in food assistance programs, such as WIC, SNAP, and free and reduced-price school meals.WIC is the ultimate fruit-and-veggie prescription program. The WIC food package makes permanent increases for fresh and vegetables benefits for millions of eligible WIC participants across the country. Children’s benefits for fruits and vegetables are $25 per month (up from $9) and pregnant and postpartum participants rise to $44–$49 per month (up from $12).Federal Nutrition Programs Improve Health OutcomesAn ever-growing body of research underscores how participation in these federal nutrition programs is a winning strategy to improve nutrition and health.As the largest federal nutrition program, SNAP has a profound impact on population-level economic, nutrition and health outcomes— particularly when its benefit levels are adequate for purchasing healthy foods. Enrollment in SNAP is linked to improved health outcomes, better medication adherence, and lower risk of heart disease and obesity. In addition, SNAP is linked to better access to preventive healthcare and reduced healthcare. Findings from a study of more than 60,000 older adults with low incomes show that one year after participants start receiving SNAP, they are 23% less likely to enter a nursing home and 4% less likely to be hospitalized.WIC was established in 1972 as a medically tailored public nutrition intervention for at-risk mothers and children. WIC is the original “Food Is Medicine” program, proven to prevent obesity and improve food security, dietary intake, birth and health outcomes, and economic stability. The longer children participate in WIC, the healthier their diets. Extensive research suggests that WIC contributes to better birth outcomes and healthier babies. In fact, a study conducted in 2019 by Nianogo, et al., showed that participation in WIC resulted in cost savings, including both savings pertaining to WIC intervention costs as well as savings due to tangible and intangible costs associated with pre-term birth.School MealsThe National School Lunch Program—the nation’s second largest food and nutrition assistance program—makes it possible for school children in the U.S. to receive a nutritious lunch every school day. Millions of children also benefit from school breakfast each day. Children of families at low or moderate income levels can qualify for free or reduced-price school meals.Meals must meet federal nutrition standards, which currently require schools to serve more whole grains, fruits and vegetables. Participation in school meals has favorable impacts on a number of outcomes, including food security, dietary intake, obesity and health status. Research has demonstrated that school meals are the healthiest meals that many school- children eat during the day. Research shows that students who participate in the school meals programs consume more whole grains, milk, fruits and vegetables during mealtimes and have better overall diet quality than nonparticipants.Steps Healthcare Providers Can TakeHealthcare providers, bolstered by anti-hunger collaborators, can ensure patients are accessing SNAP, WIC and other federal nutrition programs by utilizing a range of strategies and resources, such as FRAC’s online course, “Screen & Intervene: Addressing Food Insecurity Among Older Adults.” Healthcare providers use various approaches to connect patients to SNAP and WIC, including two types of food referrals.Passive referrals: Healthcare providers give patients information about food resources, including information on SNAP, WIC, other federal nutrition programs, and additional resources such as food pantries. In some cases, handouts may include more detailed—and often localized—information on how to access SNAP or WIC from pertinent agencies. Healthcare providers may also use texting to promote opportunities to connect patients to SNAP and WIC.Active referrals: Healthcare providers connect patients with programs either through on-site assistance or through referral partnerships. Through on-site assistance, patients are referred to full- or part-time on-site case managers, patient navigators, community health workers, resource coordinators or social workers, who assist them in applying for SNAP or WIC. Through referral partnerships, healthcare providers can collaborate with state or local community-based orga- nizations or agencies. Examples include creating a process by which patients who are interested in being connected to SNAP and WIC consent to a partner organization reaching out to them; hosting a partner organization or agency at the health provider site who provides patients with assistance applying for SNAP or WIC; and/or developing a formal Memorandum of Understanding (MOU) with partners to provide SNAP and WIC application assistance.Healthcare providers can leverage the growing efforts around the Office of Disease Prevention and Health Promotion’s Food Is Medicine program as one opportunity to connect patients to the federal nutrition programs. The Department of Health and Human Services considers Food Is Medicine to include “approaches that focus on integrating consistent access to diet- and nutrition-related resources” as a critical component. Connecting patients to the federal nutrition programs fits within this approach and constitutes an important primary intervention.Section 1115 waivers should be considered. Section 1115 waivers (sometimes known as Section 1115 demonstrations), allow states to experiment with new approaches to Medicaid and to tailor portions of it, such as by testing new services. As states continue to be approved for Section 1115 waivers for medically tailored meals, groceries, and other nutrition interventions, these services should supplement, not supplant, existing federal, state and local nutrition supports. State Medicaid agencies should partner with other state agencies and social service providers to ensure that beneficiaries experiencing food insecurity are connected to programs like SNAP and WIC. Medicaid also needs to explain how it will track and improve upon enrollment in SNAP and WIC.Research continues to grow and evolve on the healthcare sector’s increased awareness of patients’ health-related social needs—including food insecurity—and its efficacy addressing these needs. Yet, while many healthcare providers are connecting patients to SNAP and WIC, the published literature that looks at healthcare providers connecting patients to SNAP and WIC is limited.Future Study RecommendationsToo few of the published studies provide needed insights as to how healthcare providers are creating sustainable systems to connect patients to SNAP and WIC. Given the vital role of these programs to patient health, it is important to understand how healthcare organizations can sustainably provide screening and active referrals (whether on-site or provided by another organization).Future research is needed to improve the efficiency and cost-effectiveness of active referral systems, as well as ways to continue moving toward broader systems improvements such as seamlessly connecting people to Medicaid, SNAP and WIC through fully integrated applications.Additionally, we still have significant limitations in understanding the full scope of patients who may be at risk of food insecurity, as well as those who could benefit from referrals to food assistance programs. Many studies highlight the stigma and social vulnerability associated with sharing food insecurity and other social needs with healthcare providers. Studies also suggest that families may underreport social problems. In addition, the screened population may not be representative of the overall population because universal screening is not always implemented in healthcare. More qualitative surveys would be beneficial to understand families and their experience with food insecurity and how best to connect them with supplemental resources.More research is needed to assess individual knowledge, attitudes and beliefs around screening for food insecurity and around SNAP and other food benefit programs. Specifically for WIC, research is needed on effective strategies to improve the retention of children older than 1 year. Future work should focus on understanding how to increase the rate at which those who are reporting food insecurity are being linked to resources.A significant body of evidence suggests that enrollment in SNAP and WIC improves health, helps manage chronic disease, and reduces health cost and utilization. Likewise, children’s participation in school meals favorably impacts food security, dietary intake, obesity level and health status. As screening for food insecurity continues to proliferate, it is imperative that healthcare providers are educated on the importance of SNAP, WIC and other federal nutrition programs as primary interventions to improve health outcomes and on which methods to connect patients to these programs are most effective.Healthcare providers can play a key role in closing participation gaps in access to nutrition programs. Planning is needed to determine whether healthcare providers have capacity for a passive referral or an active navigation model, with the goal of eventually establishing a sustainable, effective process that is integrated with their electronic health system. Future research should build out evidence-based best practices that healthcare providers can tailor to their circumstances and integrate in their standard practice for screening and intervening.Building sustainable healthcare systems to ensure every eligible patient is connected to SNAP, WIC, school meals and other federal nutrition programs is a winning intervention to address food insecurity and improve health.The Food Research & Action Center improves the nutrition, health, and well-being of people struggling against poverty-related hunger in the United States through advocacy and partnerships, and by advancing bold and equitable policy solutions. For more information about FRAC, or to sign up for FRAC’s e-newsletters, visit www.frac.org. For research citation, visit https://bit.ly/40mjMLs.

### Rattle When You Walk?
Mom was going through a “phase.”
At that time, we lived in Northern California, transferred there courtesy of my father’s naval career. It was the late 1960s. I was 7 years old, and my older brother Robert was 8 and a half. My younger brother Michael was exempt, only being 2.
Exempt from what?
Mom had heard about supplementing the diet for health. I don’t know what her sources were, back in days of yore before internet—perhaps some ladies’ magazine. However, she decided that both she and we needed a supplement drink in the mornings before leaving for school.
What was her dire concoction? All whirled up in our family’s avocado green Oster blender was a combination of whole milk, a raw egg, a large dollop of orange juice concentrate from the can, a heaping scoop of Brewer’s yeast, and scoops of various other powders—dunno what. Robert and I would have to drink about a cup of the vile and retch-inducing blend before being released to go to school.
Our torture ended when Dad took up arms on our behalf, arguing that Mom could drink anything she wanted, but that we kids should be liberated from drinking the brew if we wanted to quit.
Spoiler alert: We quit.
Flip forward to today, when the internet abounds with pro-proprietary capsule- and shake-supplement blends with limited science to support their use. Although not near as gag-worthy as Mom’s blend, it’s hard for the average person to figure out which claims are worthy of belief and one’s cash. I understand the dilemma; with aging, disease, aches and pains, I take three mainstream pharmaceuticals and 11 (!) nutraceuticals—it’s quite the laughable mountain of multicolored capsules and tab- lets that emerges from my extra-large pill sorter each morning. But are the supplements science-worthy?
I did a second-opinion consultation a couple months ago for a “young” man (early 30s) who was consulting for cryptic elevation in liver tests of recent onset that had stymied his local gastroenterologist. Negative liver serologies, celiac testing, and ultrasound imaging left his physicians shrugging.
At our video chat, he disclosed that he had been fatigued recently; could it be his liver? Digging deeper, it turned out that he had been taking four to five various supplements that were “guaranteed” to give him more energy. The time of onset of his fatigue? Eight months—the age of his first son. Hmmm. I suggested he stop the supplements, and, why yes, his liver enzymes normalized on repeat testing. His new-father fatigue will likely improve when his son deigns to sleep through the night.
So, how do I choose what supplements to take?
The supplement in question needs to have peer-reviewed and published clinical
I add only one new supplement at a
I reassess in one month/bottle. If questionable improvement in symptoms, I stop the supplement and see if symptoms If asymptomatic, are there possible lab tests to verify improvement?
I review supplements every six months, because science changes.
Here is a list of what I choose to take daily, minus the prescriptions:
Women’s MVI, Vitafusion 2 qDBiotin, 5000 mcg qDTurmeric, 2 grams qDOmega 3, 2000 mg (vegan, not fish oil)CoQ10, 100 mg qDAmla fruit, 1 gram qDB12, 1000 mcg qDMagnesium oxide, 300 mg qDVitamin D3, 5000 IU gelcap qDBoswellia serrata, 500 mg qDQuercetin, 500 mg with Bromelain, 100 mg qD
So let’s take my semi-annual, objective, virtual hike up my pill mountain together.
Vitamins: MVI, B12, Vitamin D3
Growing evidence supports that a daily multivitamin may not be very useful for good health. Unless you have a documented vitamin deficiency, or risks of one (like being vegan or over 60 years old), a daily multivitamin while consuming a healthy diet is unnecessary. There is a study that supports use of multivitamins in women reducing cardiovascular mortality (HR: 0.65), although no such benefits are seen in men.
Although a meta-analysis on multivitamin use demonstrated reduction in cancer was observed in men, no such reduction was observed in women; meta-analysis concluded, “Evidence is insufficient to prove the presence or absence of benefits from use of multivitamin and mineral supplements to prevent cancer and chronic disease.” So, while I have enjoyed the daily “snack” of the two tasty gummies, I will not be reordering when I complete my current bottle(s).
However, being (mostly) vegan and over 60, the daily B12 is important, since 10-15% of the over-60 population is low in B12.
As for vitamin D, I have a documented moderate vitamin D deficiency despite my gardening sun exposure. Standard replacement doses of 2000 IU didn’t normalize my levels, but 5000 IU daily did. As it is one of the fat-soluble vitamins, I have a vitamin D level checked annually to ensure that I don’t overshoot this potentially accumulating substance. Up to 35% of the population is low in vitamin D, even though the recommended dosage is a mere 600 IU daily. And there is a modest statistical reduction in overall mortality with vitamin D supplement (RR=0.93). The algorithm has changed for dosing, so if you are replacing vitamin D, make sure to check your levels annually and adjust accordingly.
However—and a reason to assess my supplement use intermittently—an August 2024 clinical practice guideline change by the Endocrine Society advocates against routine vitamin D screening or replacement in most populations. Conclusions included “no significant effect on select out-comes in healthy adults aged 19 to 74 years,” “a very small reduction in mortality among adults older than 75 years,” in pregnant women a “possible benefit on various maternal, fetal, and neonatal outcomes,” and in adults with prediabetes, “moderate certainty of evidence suggested reduction in the rate of progression to diabetes.”
Administration of high-dose intermittent vitamin D may increase falls, compared to lower-dose daily dosing. So, should I continue my vitamin D? A conversation for my internist appointment this November. Oh, how much she must enjoy my appointments!
Joint and Muscle Relief: Boswellia, Turmeric, CoQ10, Magnesium
I have knee osteoarthritis, and residual muscle weakness I attribute to long Covid. To reduce my exposure to NSAIAs for the knee osteoarthritis, I have long advocated the use of boswellia. (You’d have to pry it away from me.)
Same with turmeric; in addition to reducing OA pain, benefits include any number of health conditions, so I’ll be keeping that too.
The CoQ10 is useful in reducing statin-induced myopathy which includes pain, weakness, cramping and fatigue. As both my dad and I have experienced this myopathy, and I’m on Pravastatin (with supposedly “less” myopathy), I’ll be keeping this one. There are various mitochondrial associated benefits as well—actually too many for inclusion here.
The magnesium is to aid muscle recovery from exercise and reduce cramps. Giving myself credit here: I’m currently doing Pilates twice per week, core and balance class twice per week, water aerobics twice per week, and yoga weekly, in addition to gardening. (Yes, retirement is da bomb!) I’ll keep my magnesium, please and thank you. Hmm, I’ve run through my word allotment and have too many remaining supplements to go, so tune in next issue for T2D and dyslipidemia.
So, what has this shared semiannual review done with my supplement list? I’m dumping the multivitamin (and probably the biotin, foreshadowing the next article installment...), and continuing the turmeric, CoQ10, B12, magnesium, and boswellia. I’ll give some consideration to releasing the high-dose vitamin D with the input of my physician.
Women’s MVI Vitafusion 2 qDBiotin 5000 mcg qD pendingTurmeric 2 grams qDOmega 3 2000 mg (vegan, not fish oil): PendingCoQ10 100 mg qD: Yes!Amla fruit 1 gram qD: PendingB12 1000 mcg qD: Yes!Magnesium oxide 300 mg qD: Yes!Vitamin D3 5000 IU gelcap qD: Discussion with internist, possible discontinuation and recheck levelsBoswellia serrata 500 mg qD: Yes!Quercetin 500 mg with bromelain 100 mg qD: Pending
I believe that I, too, am going through a phase.

### Cleaning Chemistry
Cleaning is a critical part of endoscope processing. It sounds obvious, but the chemicals we use for cleaning will not function as designed unless used correctly. So, let’s review the factors that might compromise our path to a clean endoscope. 
Detergents are cleaning agents that dislodge soils and dissolve or suspend them in the solution so they can be removed by washing and rinsing. They are less likely than soap to form films (soap scum) or to be affected by the minerals in hard water. 
No single cleaning agent can remove all types of soils or is safe on all materials. Virtually all manufacturers of surgical instruments and devices recommend using a neutral-pH detergent for cleaning. 
Several factors affect cleaning but the selection and use of detergents is one of the most critical steps. So, how do we ensure this is being done? 
Steps for Effective Cleaning 
Step 1: Obtain the most current manufacturer’s instructions for use (IFU) for the scope or device to be processed. IFUs are updated by manufacturers on a routine basis, so it is important to update your IFUs on a routine basis. Frequency should be specified in a department policy. 
Step 2: Review the IFU for any changes from the IFU you currently have on file. Review the entire IFU for any new chemicals validated for use, new cleaning equipment or implements, changes in the water quality for cleaning and/or rinsing, etc. 
Step 3: Changes in any recommendations need to be brought to the attention of the department manager and the Infection Pre- vention Department. If the changes differ from the current policy for processing flexible and semi-rigid endoscopes, the zpolicy should be updated and processing staff trained in the changes. 
Step 4: If no changes are indicated, then obtain a current copy for any detergent(s) you are currently using to process your endoscopes and accessories (manually and/or mechanically). 
Step 5: Review the detergent IFU for information regarding shelf life. (NOTE: The date of manufacturer and lot number are usually printed on the bottle or container.) The chemicals usually have a lot number, manufacture date and expiration date. The chemical should be used before the expiration date. I suggest you document the information on a log form in the event of a problem with the chemical and/or a recall from the manufacturer. 
While reviewing the IFU of the detergent, look for information about the concentration needed (e.g., one (1) ounce per gallon of water). Enzymatic detergents (neutral pH) are most commonly used because of their ability to break down soils, making them easier to remove, and because of their wide material compatibility. They are the detergent of choice for flexible endoscopes as well. 
Step 6: Review the enzyme detergent manufacturer’s IFU to determine whether the enzyme is affected by water temperature and if so, what recommended temperature range should be used. If the manufacturer has specific recommendations about water temperature, processing staff should ensure a thermometer is installed in the sink or basin. During use, monitor compliance with the water tempera- ture specified in the IFU. The thermometer should be durable and easy to keep inside the sink or basin. Temperatures higher than those recommended by the enzyme manufacturer can coagulate protein and break down and/or destroy the enzymes, making cleaning more difficult. 
Temperatures below the recommended limit can result in sluggish enzymes, reducing their effectiveness. Thermometers should be cleaned as recommended in the IFU, calibrated annually or replaced. 
Step 7: No matter which device is used for dispensing detergents, it should be maintained to ensure correct dilution. If measuring cups are used, they should be cleaned between uses to prevent buildup of the detergent inside the cup, which could affect the correct amount being dispensed. Another method is using a manual pump on the detergent bottle. The pump should be cleaned routinely to prevent buildup of detergent at the dispensing spout; in addition, the amount of solution dispensed should be checked routinely to ensure it has not changed. For example, if one pump should dispense one ounce of detergent, this is easily verified by checking the measuring cup when the detergent is dispensed. However, if the amount of detergent in the cup is less than an ounce, the pump needs to be cleaned. Too much detergent is as bad as too little. Either scenario can impair the effectiveness of the cleaning process. 
If an automated system is used to deliver the detergent, it should be routinely calibrated and maintained by the manufacturer. The amount of detergent dispensed should also be verified routinely or as recommended by the manufacturer. Processing staff should be trained in the operation, care and maintenance of this system. 
Excessive detergent can also result in incomplete rinsing of the detergent, which can build up over time and interfere with high-level disinfection or sterilization of the endoscope. 
Step 8: Comply with the water-quality recommendations in the IFU. Impurities (e.g., calcium/magnesium) in water can adversely affect the cleaning process. Management should ensure the department’s water quality has been analyzed and that the water used for cleaning, as well as the initial and final rinses, meets current standards (Association for the Advancement of Medical Instrumentation ST-108 Water for Processing of Medical Devices 2023). If not, management should work to attain compliance with the standard. 
Summary 
Cleaning medical devices requires knowledge, education, the recommended chemicals, using those chemicals according to the IFU, and monitoring compliance with the IFU. The device manufacturer is responsible to validate which chemical(s) have been tested for efficacy on their devices. But endoscopy technicians must comply with the IFU for the chemical selected. In addition, for staff safety, PPE should be worn when working with cleaning chemicals. However, check with the detergent IFU and Safety Data Sheet to see if any special PPE is required. If so, it should be purchased and staff trained in its use. Cleaning can be adversely affected when we do not comply with the device and chemical IFUs. Compliance will ensure staff safety and facilitate the cleaning process for devices being processed. 

### Small but Mighty
A renowned nonprofit healthcare provider and insurer, the University of Pittsburgh Medical Center, or UPMC, is committed to delivering patient-centric care via technological and clinical innovation, research and education. With more than 100,000 dedicated employees, the health system provides more than $2 billion in annual community benefits.
Tucked in a corner of the hospital in Harrisburg, Pennsylvania, the endoscopy department/GI lab includes a waiting room, eight bays for admissions and recoveries, three procedure rooms, and a decontamination room for high-level disinfection.
“We do a combination of outpatient and inpatient procedures in our department,” said Letitia Ritzman, endoscopy technical specialist. “Some interventions may include esophageal dilation (balloon and Savary), EMR, variceal banding, APC, decompression, stent placements and removals, foreign body removal, and food bolus removal.”
The department employs nine RNs (six full-time, one part-time, and two per diem), three endoscopy technical specialists, a high-level disinfection technician, and a control-desk coordinator. In addition, Ritzman said, the unit director—an RN—helps with staffing. Small but nimble, this dedicated team not only handles the usual panoply of GI procedures like colonoscopies, EGDs, ERCPs, and capsule endoscopies, but they also travel to the OR to assist with intraoperative scopes, or to the ICU to perform emergency scopes when a patient is too sick to be moved.
“Our team is excellent because all staff members are cross-trained to assist in multiple positions and assignments,” Ritzman said. “For example, all RNs can perform in admissions, recovery, circulating (in-procedure), technician role, and HLD room. Our technicians float in admissions and recovery to assist the nurses, ‘scrubbing’ in procedures, HLD room, and some are cross-trained at the control desk coordinator position. Our HLD technician can set up carts and order supplies. The control-desk coordinator can assist with admissions, including IV starting.
“Because we all know the amount of work involved in every position, we all jump in to help each other at any given moment without animosity. We rotate evening, weekend and holiday call between 10 staff members. Staff members pick up and trade call time for those in need or wanting vacation.”
Ritzman is particularly impressed with how readily the department director pitches in wherever needed, giving the team flexibility in granting breaks and vacation time. “Because she truly knows what it’s like to be us, she has a great understanding of where we are coming from and what we need to best care for our patients.”
Like most All Stars teams, UPMC’s endoscopy pros know how to celebrate the important moments, creating bonding experiences that make the department a great place to work. “We celebrate our team’s life events by having birthday parties, bridal showers, baby showers, and retirement parties. We have staff picnics and holiday parties. Some staff members go to concerts together while others go antiquing,” Ritzman said. Three staff members have been with the team since the 1980s—another indication of an employee-centric workplace. “It really says something about the work environment when the only time staff members leave is in retirement.”
Andrea Collier, RN, is the newest team member. Hired in July, 2024, Collier already knows how fortunate she is. “Becoming the newest member of this team in July has been amazing! From the start, everyone was welcoming, friendly, and eager to contribute to my success. I am so lucky to have found a team that works effectively and efficiently together. They truly are a well-oiled machine. Many signed up for ‘buddy call’ so I wouldn’t be alone on my first call week. Even though it went from ‘we never get called in’ to getting called in eight times my first week, I know I can depend on any member of this team.”
Ritzman agreed. “I think it’s helpful that we are cross-trained in all the roles of our department. We all know what it’s like to be in each other’s shoes (at least all that’s legally allowed without a license). As a tech, I would be lost without my nurses, and I would also be lost without my HLD technician and control desk coordinator. My nurses would also agree that I teach them something new all the time. We truly are the best team and our anonymous patient reviews reflect this, with a recent one stating, ‘You can tell they enjoy what they do and like each other.’”

### A New Year's Medley
Hello, 2025!That list of figures sounds like science fiction to me, but oh well, 2025 is now. Here we are. Having been born in 1980, I believe the year 2025 sounds like Jetsons material. Perhaps you middle-agers (and beyond) can identify. We're really not that far from The Jetsons … self-driving vehicles are zipping around, anyway.Autonomous vehicles! I still don't believe we're making enough fuss over this as a culture. Cars are driving themselves, for crying out loud, and we're like, "Oh, yeah, that's no big deal." And it won't be, soon enough.Anyway, I wish you all a good year personally, and for your practices. Here at EndoPro we will be introducing some new developments, including the return of the EndoNurse cartoon. Do you remember her? She was a sweet cartoon character that featured in every edition of our predecessor magazine, EndoNurse. She had a colleague, EndoTech, who I'm convinced was not only her colleague (wink, wink).More enigmatic was the appearance of EndoNurse's canine, Arf. I have never quite comprehended why there would be a dog in an endoscopy center. His presence wasn't exactly screaming of good infection-control procedure. I mean, Arf was no doubt licking who-knows-what. Okay, fine, dog mouths are strangely sanitary, but only if you think of it as being a dog mouth. The standards are not high.Such as, where was the Joint Commission during this comic strip? But sadly, I came into possession of the cartoon—I did not create it—and it did not feel cruel to get rid of Arf. It's not his fault that he does not adhere to infection-prevention practices, and I didn't want to disappoint EndoNurse.This year EndoNurse will begin appearing in cartoon form, but I'm not certain whether this will bring back reappearances of the actual comic strip. We'll see!Another change is that we’ll also be using an “end mark,” which is a symbol or icon at the end of an article to signify the article is done. Also, our website is going to improve this year, so stay tuned for updates there.I truly hope this will be a good year for you. Let’s all drive into 2025 with full gusto, but maybe not from a self-driving car (I’m not ready!) 

### FlexiPump Releases Independent Flushing System
The recently released FlexiPump Independent Flushing System is a hands-free automatic flushing pump that replaces syringes and spray guns for manual cleaning. FlexiPump manufactures report that it can clean up to three instruments at once and has pre-programmed flush cycles for consistent and standardized flushing. With this system, every sterile processing technician and gastroenterology nurse follows the same cleaning process every time.
The FlexiPump tube sets come with built-in pressure-relief valves to protect delicate eye instruments, robotics, and suction tips from excess pressure, meeting specific pressure IFU guidelines. The FlexiPump also has a special Impact Cycle to safely remove tough soils and clogs from internal channels.
While the FlexiPump cleans multiple devices simultaneously, technicians and nurses are free to perform other tasks. With hands-free flushing, they also avoid the repetitive motion pain and injuries associated with using syringes or holding a spray gun.
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Features to help your SPD and/or GI department
 	Comprehensive flushing system: Unlike competing pump flushing systems that only clean endoscopes, FlexiPump is tested and proven for a wide variety of reusable devices, including rigid and flexible scopes, MIS, da Vinci robotic, ocular, laparoscopic, bariatric devices, urology, orthopedic, and suction tips.
 	Safer flushing: Eliminates repetitive motions associated with syringes and spray guns.
 	Hands-free flushing: Technicians and GI nurses can focus on other tasks while the FlexiPump system automatically flushes device channels and lumens.
 	Consistent flushing: Flushes over 1000cc through multiple devices simultaneously.
 	Speed Settings: Three speed options for volume adjustments and greater control.
 	Impact Cycle: Helps disengage hard-to-remove debris and bio-burden.
 	Compatibility: Connects to most devices without luer locks and easily adaptable to connect to a variety of devices.
 	Protection: Pressure relief valves help protect scopes during flushing.
 	Cost-effective: While competing pumps need their tube sets replaced daily, FlexiPump tube sets only have to be replaced every 30 days.

### Happitum Launches Nationwide: A Natural Approach to Gut Wellness
Happitum, a gastroenterologist-formulated natural gut wellness supplement, is now available nationwide after a focused launch in the New York and Florida markets. Happitum offers a comprehensive approach to supporting digestive health and overall well-being for gastroenterology patients.
Happitum is distributed through gastroenterology offices and can also be purchased by patients directly from the website happitum.com. Since its launch in early 2024, the product has received an overwhelmingly positive reception amongst the GI community and patients for its natural ingredients, which support common digestive issues such as bloating, digestion, and stress.
"Our goal at Happitum is to provide the gastroenterology community a natural supplement that supports gut health effectively, and can be trusted by our physician partners and consumers alike," said Matt Kurland, co-founder of Happitum. "We have combined clinically supported, natural ingredients to promote calming, along with digestive enzymes to support bloating and digestion. The multifactorial formula can benefit a variety of patients who see their Gastroenterologist in need of a product that is safe and reliable without taking any drugs. Nearly everyone has gut issues due to their diet, lifestyle, and stress in general. The ingredients in  Happitum directly address these root causes.”
Happitum is GI-formulated, vegan, gluten-free, made in the USA, and undergoes rigorous third-party lab testing to ensure the highest standards of safety and efficacy. Happitum is  formulated with a blend of bioactive natural ingredients, including:
 	Peppermint, Ginger, Curcumin, Artichoke Leaf: Extensively studied ingredients that promote calming of the stomach.
 	Alpha Galactosidase and 5-Enzyme Blend (Amylase, Protease, Lipase, Cellulase,  Lactase): Supports bloating and digestion by breaking down food.
 	Ashwagandha and Theanine: Gut-brain axis support from ingredients that promote wellness and reduce stress.
 	Marshmallow Root, Slippery Elm, and Fennel Seed: Barrier protective ingredients supporting a strong digestive tract lining.
Happitum is committed to supporting healthcare providers in delivering the best care to their patients. We invite Gastroenterologists to become a Happitum Sample Partner and offer complimentary samples to their patients. Additionally, we offer QR code discounts for medical offices, as well as a wholesale program for our Physician Partners should they choose to distribute products at their office. For more information or to join one of our Partner Programs,  please contact us at info@happitum.com or visit happitum.com.
For further information, contact Happitum at info@happitum.com or visit www.happitum.com.

### Strike a Pose
Thanks to the increasingly rapid pace of medical advancement, endoscopists are encroaching on what has often been thought of as surgical territory. Procedures such as peroral endoscopic myotomy (POEM) and endoscopic submucosal dissection (ESD) are exploring the limits of the endoscope and obviating the need for once traditional surgical interventions.
Surgeons already know that angling a patient’s body during a procedure can greatly facilitate success. Laparoscopic procedures in particular often involve tilting the surgical bed, which can help avoid negative outcomes. Polise, et al., wrote, “It is useful to take into account the effect of gravity on lesion exposure, tumour traction during dissection, crushing by body weight, risk of sample drop, risk of damage to adjacent organs, and anatomical exposure for procedures with radiological support.”
The problem is that often such surgical positioning isn’t all that safe or comfortable for the patient, who sometimes has to lie on something hard or sharp or in a physically taxing position. According to the Association of periOperative Registered Nurses, or AORN, patient positioning goals include exposing the surgical site, maintaining the patient’s comfort and privacy, ensuring equipment and IVs are safe and accessible, maintaining optimal patient ventilation, maintaining circulation, protecting the patient’s organs, skin, muscles, joints, eyes, fingers and toes and genitalia, and stabilizing the patient to prevent shifting or motion.
Maggie Armstrong and Ross Moore observed in StatPearls that practitioners should consider several factors when positioning patients. Obviously the patient’s age, weight and size are major considerations, but the team should also look at the patient’s general health and medical history, including any issues with respiration or circulation.
Meeusen wrote, “There are well-established rules for [patient positioning] during surgical operations, and nurses and surgeons are well-versed in how to follow them. Unfortunately, endoscopic treatments do not have these criteria.”
In the journal Frontiers in Oncology, Li-Jun Zhou and associates agreed. “Each position carries some degree of risk which is maximized in the anaesthetized patient who cannot make others aware of compromised conditions,” they wrote. “Patients may also be transferred and positioned on operating tables whilst they are unconscious. The maneuvering and the final positioning have an impact on potential injuries sustained under anesthesia as endotracheal tubes, intravascular lines, and urinary catheters should be free to move and adequately secured before any movement. This all adds to challenges encountered by both the endoscopist and anesthetist attempting changing patient position during the procedure.”
“There are well-established rules for [patient positioning] during surgical operations, and nurses and surgeons are well-versed in how to follow them. Unfortunately, endoscopic treatments do not have these criteria.”
To help clarify patient positioning in endoscopy, Meeusen and colleagues created guidelines in the journal Gastroenterology Nursing using an observational feasibility study. “Endoscopy units face new challenges arising from the increasing numbers of complex and prolonged advanced procedures on patients who have comorbidities and are obese,” they wrote. “It would be beneficial for the latter if surgical positioning practice guidelines could be adopted during gastrointestinal endoscopic interventions.”
Under Pressure
Pressure injury in gastroenterology is no joke. In International Wound Journal, Jin et al., wrote, “[Intraoperative acquired pressure injuries, or IAPI,] intensify both the physiological and psychological burden on patients. As PI progresses, the incidence of postoperative complications goes up and the length of hospital stay is extended, thus adding difficulty to nursing and elevating the consumption of medical resources. Moreover, there is also an increase in the readmission and mortality rates of IAPI patients within 30 days after surgery.”
In an article for Research Outreach, Dr. Vera Meeusen wrote that patients “can also experience overstretching or compressing nerves and squeezing skin tissue, which can result in temporary or permanent injuries/damage.”
In addition, IAPI is one of the criteria examined by tertiary general hospitals when evaluating clinical care quality and quality improvement efforts.
While studies have examined anesthesia duration, skin temperature and total time of low diastolic blood pressure to help identify IAPI, the primary cause of injury is direct force of continuous pressure on the patient’s skin.
Jin and associates found that “micromovement” for patients undergoing surgery in the supine position reduced the incidence of IAPI by five times over the control group. This movement—accomplished by tilting the surgical table.
15 degrees to the left and then 15 degrees to the right, maintaining the tilt angle for five minutes and alternating every hour—also yielded reduced relative skin temperature differences in the region under pressure, as well as leading to increased job satisfaction in nurses.
Jared Bilski, the editor-in-chief of Outpatient Surgery Magazine, wrote, “A major part of proper positioning involves pressure ulcer prevention, which often comes down to paying close attention to problem areas inherent in the various positions and getting foam or gel rollers underneath the patient’s legs, hips or any other vulnerable areas.”
Assume the Position
Patients generally are placed in one of three positions prior to a procedure: prone (face down, generally with the head turned to the side), lateral (lying on one side or the other), or supine (lying on the back). Each position has its challenges and advantages.
The lateral position is often used for endoscopic procedures. In addition, patients who can’t tolerate being placed in a prone position—such as those who are obese or pregnant— are placed in the lateral position. To prevent peripheral nerve damage, a nurse or technician will place a pillow between a patient’s knees. In right-handed physicians, Somchai Amornyotin wrote in the Journal of Clinical Anesthesia and Intensive Care, “the left lateral position is usually used for esophagogastroduodenoscopy and colonoscopy procedures.”
Zhou wrote that patient positioning was an important element during full-thickness resection of large gastric tumors when the patient is under general anesthesia. “Typically,” they wrote, “the patient is placed in left lateral position for the endoscopic therapy, and during the procedure, [the] patient’s position is changed to maintain the tumor above the gastric fluids to prevent gastric juices and tumor or tumor fragments from falling into the peritoneal cavity in the event of perforation.”
Preplanning, they wrote, is critical. Endoscopy combined with CT scans can help accurately pinpoint the location of the tumor so the clinician can then decide which position will create the most beneficial outcome. “The supine position (include anterior lateral) and left lateral position is convenient for most patients requiring endoscopic full-thickness resections. For patients where the tumor is located on the posterior wall and greater curvature of gastric body and fundus, the prone position or right lateral is best.” They added that water can be injected into the gastric cavity to ensure the placement will be best for the patient and procedure.
It is also possible to perform ERCP in the left lateral position; however, this is not recommended because it can cause pancreatic duct cannulation. On the other hand, the posi- tion can reduce the risk of aspiration. Clinicians weigh the pros and cons of each position and determine what is best for the patient.
The prone position can be a minefield of physiological changes. Increased intra-abdominal pressure. Labored respiration. Increased systemic vascular resistance and decreased venous return. The potential of hypoxia during sedation.
That said, the prone position is ideal for fluoroscopy and radiologic imaging. Using it, as is standard, for endoscopic retrograde cholangiopancreatography (ERCP) can mean a higher technical success rate, but also an increased rate of adverse events. In addition, it’s a difficult position to change on the fly, which can be a real problem if resuscitation becomes necessary. “For this reason,” Amornyotin wrote, “general anesthesia with tracheal intubation is used for ERCP in the morbidly obese patients.”
The supine position’s challenges include impaired respiration via upper airway obstruction, reduced tidal volumes and regurgitation. But supine is the position of choice for percutaneous endoscopic gastrostomy, and it’s also potentially beneficial for airway management during ERCP. “Previous studies demonstrated that technical success of therapeutic ERCP in the supine patient positioning was high and no increased need to use needle-knife papillotomy,” Amornyotin wrote. “However, ERCP performed with the patient in the supine position was often more difficult technically.” They also observed that the supine position created a “higher risk of adverse events” in nonintubated patients than when patients were in the prone position.
Amornyotin wrote, “Particular care is needed for positioning anesthetized patients to avoid passive movements that would not normally be tolerated. Poor positioning can create pressure necrosis and peripheral nerve damage.”
There are more positions, of course, which depend on surgical specialty and necessary requirements.
But Will it Play in Peoria?
Just as every doctor has a slightly different way of doing things, each endoscopy department might, as well. A team in Peoria, Arizona might handle patient positioning completely differently than the way a team in Peoria, Illinois would. And this can create real problems for nurses and technicians, and—by extension—patients. AORN offers tips and keys to help departments standardize this process. This is no small challenge, especially as teams change and new hires come aboard. Bilski wrote, “Even the most seemingly insignificant variations in your positioning processes can cause major safety issues for your patients.”
And it’s definitely a team effort. Per AORN, the RN, anesthesiologist, surgeon and other nurses and techs should act as patient advocates. “Perioperative team members are responsible for maintaining the patient’s autonomy, dignity, and privacy and for representing the patient’s interests throughout the procedure. Some elements of patient positioning are core to anesthesia practice; therefore, the ability of the perioperative team to support the activities of the anesthesia professional is essential.”
Zhou, et al., agreed, emphasizing the importance of allowing the anesthetist to take charge of moving the patient once the patient is under general sedation. “If the patient position needs to be adjusted during endoscopy therapy, extra care must be taken to secure and tape the endotracheal tube to prevent dislodgement while the patient is left lateral or prone or during position changes. Placing an anesthetized patient in the prone position requires the coordination of the entire staff (endoscopist, anesthetist, nurses),” they wrote.
A complication of improper position can include peripheral nerve injuries, which can be difficult to prevent.
During the process, the anesthesiologist will maintain stabilization of the cervical spine and monitor the trach tube, which should be disconnected from the circuit before shifting the patient from a supine to prone position. “Which, and how many, lines and monitors are disconnected during the
shifting is up to the clinical judgment of the anesthesiologist. Ventilation and monitoring should be resumed as rapidly as possible,” Zhou wrote.
Educating staff on the aspects of proper positioning is critical to success. AORN stated that every team member should be responsible for understanding the nuances and potential pit-falls of shifting a patient. They wrote, “All perioperative team members involved in positioning activities are responsible for:
 	understanding physiologic changes that occur during operative and other invasive procedures;
 	evaluating the patient’s risk for injury based on an assess- ment of identified needs and the planned operative or invasive procedure;
 	anticipating the surgeon’s requirements for surgical access;
 	gathering positioning equipment and devices;
 	using positioning equipment and devices correctly;
 	verifying device and equipment integrity;
 	monitoring the patient during the procedure;
 	applying principles of body mechanics and ergonomics during patient positioning;
 	respecting the patient’s individual positioning limitations; and
 	implementing interventions to provide for the patient’s comfort and safety and to protect the patient’s circulatory, respiratory, musculoskeletal, neurological, and integumentary ”
Both patients and personnel risk injury if patient positioning is performed incorrectly. Patients are especially vulnerable when under sedation or anesthesia, as their reflexes are blunted and they can’t tell you what their bodies are feeling.
A complication of improper position can include peripheral nerve injuries, which can be difficult to prevent. Such injures are caused by a combination of factors, including stretching, compression, ischemia, and transection, and individual systemic factors like inflammation or hypotension. A stretching injury can cause damage to the neck or spine. A compression injury, on the other hand, can cause edema, ischemia or necrosis.
Standardization, Bilski wrote, starts at the top. Protocols should be tattooed on everyone’s eyeballs, and new hires especially should have the freedom to ask questions or request help. The company culture should welcome questions to ensure everyone’s on the same page.
Before surgery, interview the patient. Talk about issues with lower back, neck, hips or knees. Ask about prior drug re- actions or interactions. Have they had any past surgeries? Review their med- ical history. Be thorough. Go over the prep process—fasting, meds and other necessary changes in their routine.
And be kind. Many patients may be afraid of an upcoming procedure but won’t want to admit it. Give them as much information as you can without overwhelm. Ask what concerns they may have—whether before, during or after the procedure—and what you can do to help allay their worries. Be an advocate.
Organize positioning materials before you need them. And, Bilski wrote, “Focus on the fundamentals. A major part of proper positioning involves pressure ulcer prevention, which often comes down to paying close attention to problem areas inherent in the various positions and getting foam or gel rollers underneath the patient’s legs, hips or any other vulnerable areas.” Pay particular attention to heels, knees, elbows, fingers and toes. Also examine whether you have enough team members to help with positioning. Lisa Croke wrote in AORN Journal, “Good planning allows the perioperative team to ensure the equipment works correctly and helps to avoid last-minute problems.” In other words, focusing on being proactive means your team will have to be less reactive.
Then bring the team together just before the procedure to cover details and coordinate care. This includes anesthesiologists, surgeons, nurses and techs. The briefing should include potential problems or issues such as cardiology challenges, respiratory conditions or obesity. Anything that came up in the patient interview should be shared with the team, including fears and concerns.
Patient positioning is a challenging aspect of patient care. However, the educational materials and resources available can help practitioners, nurses and technicians to avoid potential pit-falls that can cause injury, and empower them to provide each patient with the best possible care.
For article references, visit www.EndoProMag.com.

### Infection Prevention to Device Maintenance
Esophageal dilators are vital in treating esophageal strictures and related conditions, significantly improving patients’ swallowing ability and overall quality of life. Ensuring these devices are correctly stored is crucial for maintaining their efficacy and patient safety. This article explores the critical role of esophageal dilator storage in infection control and optimal dilator performance, highlighting advanced storage solutions and best practices based on established infection control guidelines.
Esophageal dilators, such as bougies (Maloney and Hurst) over-the-wire (OTW) dilators, are used to widen narrowed areas of the esoph- agus. These devices help manage conditions such as achalasia, esophageal strictures, and Schatzki rings, improving patients’ ability to swallow and overall quality of life. Given their critical role, these instruments must be pris- tine to prevent procedure complications.
Importance of Proper Storage: Infection Control
Cross-Contamination Prevention: Esophageal dilators, exposed to mucous membranes and bodily fluids, are susceptible to microbial contamination. Proper storage reduces the risk of cross-contamination between patients. The Centers for Disease Control and Prevention (CDC) emphasizes adherence to strict cleaning and storage protocols to prevent healthcare-associated infections (HAIs).
Advanced Storage Solutions: Incorporating high-efficiency particulate air (HEPA) filters and 405-nm LED disinfecting lights in storage solutions can significantly minimize microbial load. HEPA filters capture 99.97% of particles as small as 0.3 microns, ensuring a clean storage environment. Studies show that 405-nm light effectively inactivates pathogens, enhancing infection control.
Positive-Pressure Ventilation: Maintaining positive-pressure ventilation in storage areas is crucial for preventing airborne contamination. Airborne particles outside the storage cart are directed outward, helping maintain clean conditions.
Maintaining Device Integrity
Preventing Physical Damage: Proper storage systems avoid physical damage to dilators, such as bending or kinking, which can compromise functionality. Vertical storage carts, for instance, keep OTW dilators hanging straight, promoting lumen straightness and proper drying.
Organized Storage: Storage carts and cabinets with designated slots or trays ensure that each dilator is stored separately. This organization prevents dilators from contacting one another, reducing the risk of damage and contamination.
Drying
Eliminating moisture is crucial following the processing of dilators, as leftover humidity creates an environment conducive to microbial growth while the devices are stored. If not properly dried, these instruments might become breeding grounds for waterborne illnesses, including Pseudomonas aeruginosa, enabling these germs to thrive and produce resistant layers known as biofilms. The best practice suggests wiping each instrument with a clean, lint-free cloth or a special wipe designed to prevent lint residue.
For guidewire lumens, forced-air drying techniques such as pressured, oil-free instrument air or air filtered through a HEPA system are recommended. Moreover, having a specific section or station within the facility to dry these instruments is best, keeping them ready for safe use or storage. Always consult and adhere to the drying instructions provided by the device manufacturer to ensure efficacy and safety.
Comparative Analysis and Features of Advanced Storage Systems
When selecting storage solutions for esophageal dilators, factors such as capacity, mobility, ease of use, and the level of protection must be considered. Advanced storage systems, including vertical and horizontal storage carts and wall-mount storage cabinets, are designed to ensure infection control and maintain device integrity.
Vertical Storage Carts: These carts, which can hold up to 72 dilators, feature HEPA filtering systems, 405-nm disinfecting lights, and electronic keyless locking systems. They promote lumen straightness and proper drying, making them suitable for larger facilities with extensive equipment needs. A vital advantage of these mobile carts is their ease of movement, allowing them to be effortlessly transported in and out of procedure rooms and between different departments, facilitating workflow efficiency and adaptability to various clinical settings.
Horizontal Storage Carts: These carts can hold up to 72 dilators and incorporate similar advanced features. They use a unique tray system to separate dilators and promote cleanliness and organization. This design is ideal for silicone dilators that cannot be hung vertically. Like their vertical counterparts, horizontal storage carts are designed for mobility, quickly moving through the healthcare facility to provide accessible storage solutions wherever needed. However, they may require more space.
Wall-Mount Cabinets: With a capacity of up to 48 dilators, these cabinets offer a slim design with key locking systems, HEPA filters, and 405-nm disinfecting lights. While they provide a space-saving solution that ensures secure and contaminant-free storage, wall-mounted cabinets lack the mobility of cart-based systems. Still, they are ideal for smaller settings or areas with limited space.
Labeling and Organization: Each dilator should be appropri- ately labeled and stored in an organized manner to facilitate easy identification and retrieval. Designated slots or trays can prevent physical damage and reduce the risk of cross contamination.
The benefits and drawbacks of each system must be weighed against the facility’s requirements to ensure optimal performance and infection control.
Best Practices for Infection Control in Esophageal Dilator Storage
To optimize infection control and ensure the longevity of esophageal dilators, healthcare facilities should adhere to the following best practices.
Cleaning Protocols and Documentation: Follow manufacturer instructions for cleaning storage units and dilators. Use hospital- grade disinfectants and ensure high-touch areas are cleaned regularly according to facility guidelines. Document all storage unit cleaning either on paper or digitally with a tracking system.
HEPA Filter Replacement: To maintain optimal air quality within the storage units, replace HEPA filters every six months or upon visible dirt accumulation.
Proper Handling and Storage
Storage Procedures: Store dilators according to manufacturer guidelines to prevent damage. Ensure they are placed in designated slots or trays without touching other instruments.
Locking Systems: Use storage units’ locking features to secure dilators and prevent unauthorized access, reducing the risk of contamination.
Education, Training and Inspections
Staff Training: Regularly train staff on proper handling, cleaning, and storage protocols for esophageal dilators. Emphasize the importance of infection control and device maintenance to prevent HAIs and ensure patient safety.
Routine Inspections: Conduct routine inspections of the storage area and equipment to ensure compliance with storage protocols and promptly address any issues. Any signs of wear, damage or contamination should be addressed immediately to maintain the efficacy of the dilators.
Reprocessing of Dilators in Healthcare Facilities
The Association for the Advancement of Medical Instru- mentation (AAMI) recently published a technical report (TIR99:2024) for correctly processing dilators in healthcare facilities. This report assists in making dilators safe and ef- fective for use in patient care by providing precise and com- prehensive information on the selection and use of cleaning, disinfection and sterilization systems cleared by the U.S. Food and Drug Administration (FDA) for use in hospitals and other healthcare facilities.
This technical report also emphasizes the importance of following the manufacturer’s written instructions for use (IFU) and selecting the appropriate cleaning, disinfection and/ or sterilization methods based on the types of procedures performed. The report classifies dilators based on infection risk: Critical devices must be sterile; semi-critical devices require high-level disinfection or sterilization; and non-critical devices should undergo low or intermediate-level disinfection. It also emphasizes the importance of proper transport and storage to maintain cleanliness, the design of processing areas to prevent contamination, and the need for ongoing personnel education and competency verification to uphold safety and effectiveness in patient care.
Proper storage of esophageal dilators is essential for infection control and optimal performance. By incorporating advanced storage solutions with features like HEPA filters and 405-nm disinfecting lights, healthcare facilities can minimize contamination risks and maintain device integrity. Adhering to best practices in cleaning, maintenance and storage will enhance patient safety, reduce healthcare-associated infections and ensure the effective use of esophageal dilators in gastroenterological procedures. As we progress, continuous innovation and adherence to stringent protocols will be vital to advancing the standards of care in this critical aspect of healthcare.
For article references, visit www.EndoProMag.com.
The views expressed herein are those of the author(s). They do not necessarily represent the views of EndoPro magazine, 7 Toes Media, or their staffs, contributors or advertisers. All legal and other issues must be independently researched.

### Fiber
The breeze from your eyes rolling is fluttering my bangs. Fiber.
Fiber, fiber, fiber!
If you’re at a certain age, those last three “fibers” bore a strik- ing resemblance to the Brady Bunch litany, “Marsha, Marsha, Marsha!” I’ve just experienced another birthday, so it must be time to revisit fiber. Middle age is when you choose your cereal for the fiber, not the toy.
I know you don’t believe that fiber makes for sexy reading. However, the fiber story has likely changed since you last visited it—enough so that it’s well worth a reread, and then give your fiber intake some attention as a simple marker of improved gut flora and overall nutrition. And you can relax; this is not an arcane story about the anti-constipation value of fiber, cutting into what is an estimated $80 billion “poop-ease” industry.
The story is that of our nation’s pitiful Standard American Diet (SAD)—a “sweet-meat” diet high in animal proteins, saturated fats, processed foods and simple sugars—with a concomitant drop in whole foods and plant intake. That is—a drop in fiber. Animal proteins contain ZERO FIBER (a shocker to many citi- zens and a marker of failure of our high-school health classes), and the processing that processed foods undergo is generally the removal of fiber.
People don’t want to hear about your diet. Just shut up, eat your fiber, and be sad.
The changes wrought from a suboptimal diet are rapid: It’s been demonstrated that after just two days of adding animal protein intake and reducing fiber intake in a vegan’s gut, their microbiome can shift to a bacteria population that produces triple the amounts of deoxycholic acid, a toxic secondary bile acid that promotes evil DNA change of the colon lining.
A healthy and diverse gut microbiome demands MACs, micro- biota-accessible carbohydrates. MACs are the fiber found in whole-plant foods and resistant starch, mostly in beans, peas, lentils and whole grains. They cannot be digested by humans without the aid of your microbiota. If you don’t consume ade- quate MACs, your gut flora will eat the mucus in your digestive tract, altering your immune system and leading to increases in allergies and autoimmune disorders.
Your gut demands a lot of fiber. But why should gastro-folk care?
You’re endo pros! In a study looking at adenoma and advanced adenoma incidence with self-reported/recalled fiber intake, the median fiber intake of participants was a measly 23 grams daily. Yet there was a significant reduction in both adenoma and advanced adenoma rates in the highest group of fiber consumers.
The humans of yore in Paleolithic (think “stone tool”) times ate a lot more fiber, even as we romanticized them as cave- man carnivores—about 100 grams daily, based on fecal fossil study. (Is there a more poopy job than working in our field of gastroenterology? Apparently so.)
In the early 1970s, surgeon and identifier of Burkitt’s lympho- ma, Denis Burkitt, demonstrated based on population immi- gration studies a goal of at least 50 grams a day of fiber for colon cancer prevention. The main discussion now is whether it’s the fiber and MACs themselves that do the trick, or the phytochemical-rich, plant-based diet and exclusion/replace- ment of saturated fats. And need we really tease out the cor- rect answer, or just advocate a richer plant-fiber and unpro- cessed-food diet?
Apparently, you need to eat healthy more than once to improve your health. This is cruel and unfair.
What else can this magical fiber do?
Higher dietary fiber intake is associated with a reduced risk for diabetes, heart disease, certain cancers, weight gain and obesity, in addition to softer poops.
The lower risk of heart disease is quite significant, with a 9% lower risk for every additional 7 grams per day of total fiber consumed. Read that again: 7 grams of fiber is a half-cup of beans. Name something else with a 9% bang for your buck!
In the NHANES study, where the participants ate a measly average of 16 grams of fiber daily, high fiber intake was negatively correlated with inflammation, metabolic syn- drome and obesity.
And where knee pain from osteoarthritis is concerned, dietary fiber reduces that too, hypothetically by reducing both weight and systemic inflammation.
Cancers with reduced risk via high fiber intake include the expected GI cancers (stomach, pancreas, colon polyps and colorectal), but also breast, endometrial and prostate cancer. Less strong evidence supports reduction of risks of esophageal, renal cell and ovarian cancer in a recent huge meta-analysis.
And every 20 grams of fiber a day was associated with a 15% drop in breast cancer risk.
Studies have demonstrated that your tummy and diet full of fiber isn’t simply displacing “bad foods,” but yielding mechanistic effects in the secretion, turnover or metabolism of insulin, glucose, adiponectin, interleukin-6, free fatty acids and triglycerides.
If you’re like most in medicine, you can’t confidently educate your patients (and yourself) on what your fiber targets should be.
The USDA’s Dietary Guidelines for Americans (being pretty wimpy compared with Burkitt’s daily 50-gram mandate, in my humble opinion) suggests that targets should be:
 	25–28 grams per day for women under 50
 	22 grams per day for women 51 and older
 	31–34 grams per day for men under 50
 	28 grams per day for men 51 and older
Trying to eat more fiber, and almost cut my finger off chop- ping up my salad. All I could think was, “This never happens with cupcakes.”
So how much fiber are you chewing daily? Have you even cal- culated the numbers?
There are plenty of charts to help to calculate your fiber intake—perhaps take one for a spin. The Mayo Clinic offers a good one (although they hide beans down the list—don’t ya’ll eat beans?).
For a fun graphic, check out Simple Happy Kitchen’s digital download that I myself printed up (with the aid of my local FedEx/Kinkos) and hung proudly in my kitchen to help guide my own dietary choices. (You’ll find all these links in the refer- ences at Endopromag.org.)
So your fearless author proactively launched a mission to ingest 50 grams of fiber in a day to demonstrate how simple it was to achieve. (This was during a vacation day visiting my 90-year-old mom, who is decidedly non-vegan.)
 	Breakfast: Kashi cereal (3/4 cup = 8 grams fiber) with straw- berries (1 cup = 3 grams fiber), almond milk (0 grams fiber)
 	Lunch: cherry tomatoes (1/2 cup = 2 grams fiber), chop salad (kale, broccoli, cabbage = 5 grams fiber), hummus (1/2 cup = 7 grams fiber), peach (3 grams fiber)
 	Dinner: chop salad (5 grams fiber), baked salmon (0 grams fiber)
 	Total fiber intake—and I was trying, dang it—was 33 grams of
Hmm—33 grams is a third higher than USDA recommendations for a woman of my advanced years, but only 66% of Burkitt’s 50 gram recommendations. And yes, I experienced socially unacceptable flatus from my cruciferous chop salad.
My friend told me about a wonder food that contains pro- tein, fiber and healthy fats. “That’s nuts!” I exclaimed.
I’m aware that pushing fiber is simplistic and reductionistic— like when we try to convince people to improve their health first by reducing sugar at the expense of higher fat intake, then vice versa, then high protein—however, the simple man- date may work well.
Choosing a higher-fiber diet means choosing foods that are less processed: more likely fruits, vegetables, legumes, nuts or seeds. Choosing a fiber goal and trying to eat it likely means you’ll feel more satiated—and as a bonus, you will experience excellent, big, soft poops.
You are more likely to hit a target if you aim at it.
So, what’s next for your health?
Look at what you’ve eaten/are planning to eat today and count the fiber grams. Are you achieving the USDA’s low-to- mid 20 grams? Aiming high at Burkitt’s 50 grams?
When offered dietary options, try choose the one with the highest fiber—there will be benefits beyond large, soft poops. Think of fiber not as fiber itself, but as a marker for wiser di- etary choices.
Don’t worry about which fiber you should eat. Just eat more of them all.
For article references, visit www.EndoProMag.com.

### GI Endoscope Storage Cabinets
Since the publication of AAMI ST91:2021 National Standards for processing flexible and semi-rigid endoscopes, medical device processing experts continue to observe and address flexible endoscope storage cabinet challenges and confusion.
Common questions asked are, “What kind of endoscope storage cabinet are we supposed to have and where can the cabinet be positioned and why?” Several factors determine the type of endoscope scope cabinet needed. Healthcare facilities have different financial budgets and constraints.
The square footage and footprint of a facility often present challenges that make it nearly impossible to purchase the proper storage cabinet. Most flexible endoscope storage cabinets are large and require a healthy amount of space. Flexible endoscope devices vary in complexity, length and size, and they could change the height, width, depth and space necessary to meet the storage cabinet manufacturer’s specifications. Electrical, filtration, ventilation and compressed-air requirements could affect the cost and space.
With today’s economic challenges, healthcare facilities have tighter equipment capital and operational budgets. Healthcare facilities must creatively find ways to cut costs, work more efficiently by eliminating wasteful processes and unnecessary supplies, and mitigate staffing shortages, while reducing overtime and the excessive use of contracted employees—and this is the tip of the iceberg. Healthcare facilities focus on revenue-generating growth strategies, partnerships, acquisitions or mergers to support long-term success and provide medical services to their communities. Rising equipment costs present difficult budgetary limitations for most facilities now.
Choosing the right storage cabinet is challenging, so assessing and evaluating the current state to identify potential gaps or risks in the process can often support a more cost-effective solution and plan. Most importantly, when making the decision, the outcome should result in the greatest protection for the device and the best prevention for potential recontamination and ensure that every stored endoscope is patient-ready.
Endoscope Storage Considerations
Two types of storage cabinets are outlined in the AAMI ST91:2021 National Standards. According to AAMI, professional organizations have differing views on the best storage cabinet choice. However, published scientific studies show using endoscope drying cabinets will reduce the risk of retained moisture and microbial contamination. Flexible endoscopes processed via liquid chemical sterilization (LCS) or high-level disinfection (HLD) should be stored in a cabinet that is tall enough to prevent the devices from touching the bottom of the cabinet, and has enough space (in width and depth) to allow the endoscopes to hang freely without touching each other or coiling. If using a horizontal scope cabinet, there should be enough space to store the endoscope without obstructing other stored devices.
Option 1: Endoscope Drying Cabinets
Designed to store flexible endoscopes, endoscope drying cabinets circulate HEPA-filtered or instrument air throughout the closed cabinet and through each endoscope channel at continuous positive pressure. The collective evidence shows that drying cabinets provide practical storage of flexible endoscopes to facilitate drying, decrease the potential for contamination, and provide protection from environmental contaminants (AORN, 2018 [367]).
Within the drying cabinet, the internal and external surfaces of the endoscope are intermittently or continuously dried, suppressing microbial growth. Studies related to the efficacy of drying cabinets compared with other methods of storage showed that drying cabinets effectively limited bacterial proliferation during storage of potentially incompletely dried endoscopes (Saliou, 2015 [284]; Perumpail, 2019 [254]).
Drying cabinets tend to be more costly than the conventional type. The cabinet may require routine disinfection or sterilization of the connection tubes and accessories. Compressed air is typically used to open the doors and for continuous air circulation. Reviewing and verifying that the facility can perform all the routine services and maintenance required is essential. Some cabinets have RFID badge access, keypad punch, or a swipe mechanism to open the cabinet, which is excellent for staff accountability and control.
A more popular feature seen with some drying cabinets is the built-in endoscope tracking system (AI technology or smart devices), automatic drying timers, and color-coding systems that visually indicate when an endoscope is completely dry or needs to be reprocessed (e.g., hang time). Although the up-front costs may be higher, there are advantages to using this type of cabinet, such as knowing the endoscopes are stored dry and safe for use. Drying challenges related to endoscope processing and storage continues to be a hot topic and a critical element contributing to elevated infection transmission risks.
Option 2: Conventional Drying Cabinets
Conventional cabinets are closed cabinets that enable the passive circulation of HEPA-filtered or instrument air through the cabinet or via continuous positive pressure. However, they do not include forced air through endoscope channels. When drying cabinets are not available, conventional cabinets may be used. Conventional cabinets should be cleaned following the manufacturer’s instructions for use (IFU) at least weekly, and when visibly soiled. Conventional cabinets with HEPA filtration should be used to store flexible endoscopes.
When conventional cabinets are used, the facility should monitor for indications the endoscope channels are not being dried before placement in the cabinet (drip marks in the bottom of the cabinet, etc.). If indications are noted, additional efforts should be taken to ensure drying (such as a drying time longer than 10 minutes). Storage cabinets, unless modified to provide drying, or upgraded by a third-party drying manufacturer’s IFU and approved by the storage cabinet manufacturer, do not meet the criteria to be a drying cabinet. If manual drying is used, verify the endoscope is dry. Develop and implement policies and procedures to perform quality assurance dryness checks.
Studies performed by reputable scientists and researchers cannot emphasize enough the importance of drying the endoscopes after they have been processed. The concern with conventional drying cabinets is that the air circulates and only touches the external parts of the endoscope, while the channels inside the endoscopes remain wet. If conventional drying cabinets are considered, the facility should also consider how to remove the water from endoscope channels before placing endoscopes into the cabinet.
Numerous studies have demonstrated endoscopes frequently harbor microbes after the endoscopes were high-level disinfected and revealed retained moisture after an alcohol purge followed by 10 minutes of forced air in an automatic endoscopic disinfector (AER) cycle (Cori L. Ofstead et al. 2024). Fluid retention within endoscope channels poses risks for increased transmission of residual bacteria to patients.
According to AAMI, bacteria can double in population every 20 to 30 minutes. An inadequately dried endoscope contaminated with only one or two viable bacteria can end up contaminated with tens of thousands to millions of bacteria after only eight hours of storage, magnifying the risk of transmission of infectious organisms to the next patient (Alfa et al. [54]). The exterior surface and all interior channels of flexible endoscopes should be thoroughly dried before reuse or storage.
Drawbacks to conventional drying cabinets include added operational costs for supplies, testing materials, and additional equipment needed to dry endoscopes before storage. The potential for missed drying steps, errors and inconsistent processes is higher. Mechanical drying aids can be used, but these require frequent accessory and tubing changes. The drying aid needs routine service and verification checks, which adds more steps to the workflow and process. Another way to dry endoscopes after processing is with instrument-grade air. When reviewing both options, be sure to evaluate the cost for all required supplies, additional equipment, contract agreements and quality-assurance materials.
Storage Area
Storage cabinets should be placed in an area designated as a clean space. Staffers need enough space to open cabinet doors, retrieve the scope, and place the scope in a clean trans- port container. Clean work rooms, a clean or sterile storage alcove or closet away from water sources or plumbing, or a clean area near or outside of the procedural room, is ideal. Storage cabinets should not be located inside the endoscopy procedural room (AORN, 2018e, IX.a [39]). The benefit of finding a low-traffic area that is secure and clean is that it helps protect endoscopes and prevents recontamination.
Storage cabinets should have doors and be located at least 3 feet from any sink. Ensuring storage cabinets have doors and are separated from sinks by at least 3 feet provides protection and reduces the potential for processed flexible endoscopes to be contaminated by water droplets (AORN, 2018e [39]). Cabinet doors should remain closed until endoscopes are needed. Staff will be responsible for routine cleaning and maintenance of the storage cabinet. A proper amount of space may be required for staff to clean the cabinet; service technicians need access; space is needed to change the filters periodically; and staff need the capability to process any attachments or accessories that come with the cabinet.
Shop Around and Ask Questions
When shopping for a storage cabinet, it is vital to ask the vendor or manufacturer for specification documents for installation, the technical information report or published white paper of their cabinet (if applicable), the FDA 510K Clearance document, a copy of the user operational manual to review, and a price list of replacement parts or filters that may need periodic replacement. Most equipment companies honor a 1-year warranty for parts and services. After the year ends, the facility is on its own unless there is a service agreement in place for routine and preventative maintenance. For future cost avoidance and to safeguard against common oversights during the review process, the facility should:
 	Verify that the proposed price is within the national benchmark range to avoid inflated costs or price-gouging
 	Purchase cabinets from reputable vendors or manufacturers that can provide a copy of the FDA 510K premarket clearance for the cabinet.
 	Ask to see all service agreement options and the costs associated with those options. The end user needs to understand what service is offered if or when the cabinet malfunctions, gets damaged or is defective. Response time and vendor support should weigh heavily in the decision-making process.
 	The vendor should share the most reported issues and the average cost for those types of repairs and provide a general lead time for service (especially when parts need to be ordered before repairs or service can be performed).
 	If the vendor does not offer preventative maintenance or routine services, consider other options, e.g., third-party repair services. When considering third-party repair ser- vices, proceed with caution, as using a third-party service will often void the original manufacturer’s warranty, liability and service guarantees. It is important to read all contracts and fine print.
 	Don’t limit the search to one vendor; shop
 	Ask about the cabinet’s average useful lifespan/end-of- Technology is ever-changing and advancing. Equipment will not last forever. Knowing how long the company will support the equipment with parts and services will help significantly with future budget planning. Once the cabinet becomes obsolete, the parts and services for the cabinet will be phased out and will no longer be available. Then the cabinet will need to be replaced or upgraded.
 	Find out whether the company offers future trade-ins for upgrades or obsolete All these proactive measures can prevent a lot of unforeseen costs and challenges in the future.
 	What do the other customers think about their cabinet? Ask the vendor to provide a customer reference list. Some vendors will offer a site visit to another facility to see how the cabinet is used and to connect with other process users.
 	Ask about the cabinet’s capabilities, such as artificial intelligence (AI) or innovative smart capabilities, security features, necessary accessories or adapter hookups, and passive, forced-air or active airflow.
Using ventilated cabinets with continuous, HEPA-filtered, circulating airflow that promotes exterior and internal channel drying is a best practice. Facilities responsible for processing flexible endoscopes (regardless of the device’s complexity) should evaluate and consider cabinets that provide the most ideal and effective way to reduce microbial contamination and biofilm buildup after the device is processed correctly.
Drying cabinets must support continuous air externally and inside the endoscope channels to ensure safe, ready-to-use, flexible endoscopes. Despite the industry inconsistencies regarding the exact type of storage cabinet required, the industry experts’ consensus is when endoscopes are not properly dried (or stored wet), they are most susceptible to microorganism growth and biofilm buildup, and risk transmission of infectious diseases to patients. Endoscope storage cabinets without a drying feature complicate the staff’s processing steps.
New products on the market to test and verify drying effectiveness are available for purchase through various vendors and distributors. Facilities should develop quality assurance (QA) processes to ensure residual moisture inside the channels is absent. The QA process should be incorporated into the facility’s policies and procedures, along with protocols for routine cleaning, inspection and maintenance of the storage cabinet, as well as its hoses, connectors and miscellaneous parts. Test results, cleaning and preventative maintenance should be tracked for trends and opportunities.
If the facility chooses not to purchase endoscope drying cabinets, the staff will need to thoroughly dry endoscopes before placing them in storage cabinets. Endoscopes must be purged with forced air for ten minutes at the correct pounds per square inch (psi) of pressure. This can be achieved using mechanical endoscope drying aids (with HEPA filtration) or with instrument-grade air, an air gun and a pressure regulator. Importantly, complex endoscopes (those with multi-channels, elevators and balloons, differing lengths, diameter of channels or ports) may take longer than ten minutes to dry with drying aids or compressed air. Always follow the endoscope manufacturer’s IFU and evaluate the workday time challenges this may present.
When shopping for endoscope cabinets, facilities must consider how scope drying will delay operational workflow, increase the time it takes to turn over the endoscope for following procedures, and increase the labor needed.
Time is of the essence in high-volume endoscopy facilities. Wet endoscopes should never be stored, as this presents the highest risk for infectious disease transmission between patients caused by microorganism growth and waterborne pathogens; therefore, choosing the best storage cabinet also requires evaluating the operational workflow and impact(s) to current or future volume. Utilizing drying cabinets eliminates the hands-on, laborious, air-drying step and inconsistencies associated with human factors (errors and process step variations). Endoscope storage cabinets are meant to protect endoscopes from becoming contaminated or damaged until they are used. The type of cabinet purchased determines the effects, and the risks associated with the proliferation of organisms. Choose wisely.
For article references, visit www.EndoProMag.com.

### Her Place in the Sun
In sunny Miami, Florida, Kendall Endoscopy & Surgery Center boasts a highly competent team. There is a rising star, however, at this freestanding ambulatory surgery center, and that star is Katty Hechevarria, RN, who is training to take the reins as nurse manager.
One of Hechevarria’s strengths is in team bonding, according to Maria Tarrau, BSN, RN, CGRN. “Katty has a wonderful habit of arriving at work with a positive attitude and checking in with everyone,” Tarrau said. “Her well-known phrase, ‘How is it going?’ not only reflects her genuine concern but also brightens everyone’s day. Her cheerful approach and personal touch make a significant impact on the team’s morale.
“Katty’s attitude is truly exceptional and has always been a standout quality among her co-workers, physicians and patients,” Tarrau added. “Her constant smile and eagerness to assist are just a few of the many reasons she is so highly regarded. She approaches herrole with utmost seriousness and is committed to continual improvement and learning each day. Her colleagues describe her as always ready to lend a hand, whether it’s covering a shift, handling a case, baking a cake, or organizing unit activities—whatever the need, Katty is there.”
Hechevarria’s philosophy reflects the understand- ing that while no team is perfect, a cohesive team is best composed by diverse individuals whose strengths complement one another. She recognizes the importance of fitting all the pieces together to create a well-functioning unit, and according to Tarrau, her ability to foster this sense of unity and collaboration is one of her greatest strengths.
Hechevarria’s journey with Kendall Endoscopy started in 2012, when she came on board as a GI technician. Since then, she’s earned her nursing license and made a transition back into nursing.
“Her dedication was particularly nota- ble during the COVID pandemic, when she played a crucial role as part of the elite team that kept our center opera- tional during those challenging times,” Tarrau said. Hechevarria is slated take on the role of nurse manager in 2025, when the team’s current manager plans to retire. “Her extensive experience, commitment, and leadership skills make her a natural fit for this position,” Tarrau added.
Hechevarria is part of a fantastic team that includes almost four dozen physicians, and 18 registered nurses, eight of whom are per diem. “Our per-diem staff take their roles very seriously and have demonstrated their commitment during the recent AHCA federal and state surveys,” stated Tarrau. “They received commendations for their professional attitude and extensive knowledge, showcasing their dedication and expertise.”
There are also five GI technicians, each of whom plays a key role in maintaining the highest standards of cleanliness by ensuring that all equipment, supplies and rooms are well-stocked and in top condition. Their meticulous attention to detail guarantees that everything is readily available and functioning optimally.
Six staffers compose the front office staff—what Tarrau refers to as the “first impressions team.” “This team is essential in setting the foundation for the patient experience at our center. Their efforts are consistently recognized in our surveys for their outstanding contribution to maintaining high standards and ensuring a positive environment for our patients,” she said.
Kendall Endoscopy provides colonoscopies, flexible sigmoidoscopies and upper endoscopies, as well as other gastrointestinal procedures. The center is accredited by the Accreditation Association for Ambulatory Health Care (AAAHC), and the Press Ganey patient experience survey revealed a 92% satisfaction rate among the center’s patients. Talented team members, and leaders like KattyHechevarria, are key to the success.
Retiring nurse manager Milly Garcia said, “Katty has been an absolute plea- sure to work with. She is exceptionally bright and deeply engaged in both her work and the working environment. Her dedication and well-rounded approach make her an exemplary employee and a tremendous asset to our center. I am confident that Katty will continue to be a pivotal part of our center’s future as I step down.

### SGNA 52nd Annual Course
As we look forward to the Society of Gastroenterology Nurses and Associates 52nd Annual Course (June 1–3 in Pittsburgh), I’m thrilled to invite you to join us for what promises to be an inspiring and transformative event for all gastroenterology professionals. Whether you’re a seasoned nurse or just start- ing in the field, this course offers incredible value—not just for advancing your own career, but also for strengthening and connecting with the broader GI community.
The healthcare landscape is evolving rapidly, and it is essential for us to stay informed and current with best practices and new technologies. The Annual Course is designed to help you do just that. With planning fully underway, we’re hard at work curating a program filled with sessions that will provide you access to the latest advancements in gastroenterology care, from cutting-edge technologies to innovative techniques.
You’ll have the chance to deepen your expertise, explore new perspectives, and learn about best practices that can be immediately applied in your work.
In addition to the educational opportunities, the annual course is a chance to earn valuable continuing-education credits, something we all need to maintain licensure and gastroenterology certification, and keep up with our profession’s demands. You’ll leave with practical takeaways that can help improve patient care in real-world settings.
The SGNA Annual Course is about more than just learning—it’s about community.
One of the things I love most about this event is the sense of connection it fosters.
You'll have the opportunity to network with peers, mentors, and industry leaders who share your passion for GI. These are the people who understand your challenges, celebrate your successes, and inspire you to reach new heights.
The friendships and professional relationships I’ve built at past conferences have been invaluable to me, and I know you’ll experience the same.
Whether during educational sessions, at our networking events, or while visiting the exhibit hall to explore the latest products and services, every moment is a chance to engage with your community.
I’m excited about what this coming year has in store, and I hope you’ll join us in Pittsburgh, June 1-3, 2025, for an experi- ence filled with learning, connection, growth and community. Together, we can continue to elevate the care we provide to our patients, and can stay at the forefront of an ever-changing healthcare landscape.
For more information about the SGNA 52nd Annual Course, please visit annualcourse.sgna.org.

### A New Endoscopy Credentialing System
Would the endoscopy market be improved by a new system of credentialing? I'd never asked myself that question. Never, that is, until I saw a news release issued recently by the University of Nebraska Medical Center regarding a family-medicine resident who is assisting in the development of a national universal credentialing system for endoscopists.
The resident in family medicine, Rubab Ali, M.D., is collaborating with 11 national surgical and medical societies on this effort, based on the news release. Dr. Ali recently spoke about three years of research on endoscopy guidelines and accreditation, in terms of developing a universal accreditation protocol.
Each of the various societies individually has its guidelines," said Dr. Ali. "You can observe the structure that they use in credentialing, and of course, the intent is to have high-quality patient care and safety. However each of these societies has a different structure for how to credential the endoscopist. We intend to develop universal guidelines for all societies.
Ali’s mentor and one of her collaborators is Dale Agner, M.D. The two have been working with the McGoogan Health Sciences Library and many team members. According to the news release, the collaborators have reviewed more than 500 papers each, to explore four key questions:
Should competency-based training programs; procedural, volume-based requirements; or a combination of the two be employed for the education of the next generation of gastrointestinal endoscopists?
Should credentialing in gastrointestinal endoscopy be granted on completion of a competency-based training program and passing cognitive and skill-based examination, in procedural, volume-based requirements, or a combination of these principles?
Following initial credentialing, should re-credentialing be determined by procedural, volume-based criteria, or procedure-related patient outcomes data, or clinical performance evaluation based on simulated exams?
For GI endoscopy re-credentialing, should the re-credentialing cycle intervals be of shorter or longer duration to optimize endoscopist performance metrics and patient outcomes?
It's a long process," Ali explained. "It's a hard job to gather all the societies and share research with all these societies' experts."
Ali spoke about the framework of her project at the ResQ Committee (Patient Safety, Quality Improvement, and Disparities Research Collaborative) meeting last spring. Next is to retrieve data from the accumulated papers, and to undertake meta-analysis and systemic reviews.
We have people from this sector who will be assisting," Ali said. "Then we'll be talking about what we do next. Where do we go from here?

### Fujifilm Releases New System Software
Lexington, MA, October 29, 2024 – FUJIFILM Healthcare Americas Corporation, a leading provider of diagnostic and enterprise imaging solutions, announced the launch of the Version 10 (v10) suite of innovations for ECHELON Synergy 1.5T MRI system. ECHELON Synergy v10 deploys several cutting-edge technologies, including Synergy DLR Clear, Synergy Vision with StillShot and automated scanning process enhancements.
A recent study found 15-20% of MRI scans require re-scan due to patient motion. Synergy Vision, now available for ECHELON Synergy MRI, combines multiple in-bore cameras with StillShot artificial intelligence (AI) to mitigate the impact of motion artifacts. StillShot applies AI to correct motion-compromised raw data, referencing real time motion tracking collected during the scan. Instead of repeating the acquisition, motion can be corrected, providing clearer, more diagnostic images. StillShot helps to streamline workflow for the technologist and provide a better experience for the patient.
The ”Gibbs” or “truncation” artifact has long been an image quality issue with MRI. Radiologists dealt with it or were compelled to call for longer scan time sequences to address it. Synergy v10 brings DLR Clear, a new AI based algorithm to address the truncation artifact, producing images with mitigated artifact without a scan time extension.
“Radial scanning in MRI serves as a common approach to address patient motion, but the technique faced challenges in certain circumstances from unique artifacts. Fujifilm’s v10 software enhancement was designed to help address these challenges,” said Shawn Etheridge, executive director, modality solutions marketing for FUJIFILM Healthcare Americas Corporation. “With v10, technologists can now apply our RADAR radial sequence with our iterative iRCM IP-Recon processing to mitigate spike artifacts, resulting in clear, high-quality images with reduced motion artifact”.
Deep Learning enhanced AutoPose for breast, hip and spine application are added with ECHELON Synergy’s v10. AutoPose automatic slice selection, combined with expansion to whole body application for the AutoSet automated table movement capability, and AutoStart automatic scan start on door closure can save operator steps, enable reduced total exam times, and allow technologists to better focus on patients.
Fujifilm will provide v10 software standard features to current customers at no charge as part of its unique post sales relationship.
For more information about the ECHELON Synergy MRI system, please visit the product page.
About Fujifilm
FUJIFILM Healthcare Americas Corporation is a comprehensive healthcare company that has an extensive range of technology and expertise in the detection, diagnosis, and treatment of diseases. Fujifilm’s innovative portfolio includes solutions spanning diagnostic imaging, enterprise imaging, endoscopic imaging, surgical imaging, and in-vitro diagnostics. The company is headquartered in Lexington, Massachusetts. For more information, please visit healthcaresolutions-us.fujifilm.com.
FUJIFILM Holdings Corporation, headquartered in Tokyo, leverages its depth of knowledge and proprietary core technologies to deliver innovative products and services across the globe through the four key business segments of healthcare, electronics, business innovation, and imaging with over 70,000 employees. Guided and united by our Group Purpose of “giving our world more smiles,” we address social challenges and create a positive impact on society through our products, services, and business operations. Under its medium-term management plan, VISION2030, which ends in FY2030, we aspire to continue our evolution into a company that creates value and smiles for various stakeholders as a collection of global leading businesses and achieve a global revenue of 4 trillion yen. For more information, please visit: www.fujifilmholdings.com.

### FDA Grants Clearance for Duodenoscope Sterilization Cycle
IRVINE, California: Advanced Sterilization Products (ASP), in collaboration with PENTAX Medical, announces the FDA clearance of the new ULTRA GI Cycle in its flagship product, the STERRAD 100NX Sterilizer with ALLClear Technology. The ULTRA GI Cycle is designed to reprocess duodenoscopes using hydrogen peroxide gas plasma sterilization.
The FDA clearance marks a significant milestone in advancing patient safety and addressing the challenges associated with current reprocessing methods for duodenoscopes. This sterilization cycle may revolutionize sterilization practices in healthcare facilities, according to a news release, ensuring a new standard of safety and efficacy.
Addressing Contamination Concerns
Duodenoscopes have been under scrutiny due to their relatively high contamination rates, prompting the urgent need for a robust sterilization solution. The collaborative effort between ASP and PENTAX Medical has resulted in an innovative method that not only meets but exceeds industry standards, providing healthcare professionals with a powerful tool to enhance patient safety.
“We’re proud and excited to receive FDA clearance for our new ULTRA GI™ Cycle, developed in partnership with PENTAX Medical,” said Chad Rohrer, President of ASP. “Both of our organizations are deeply committed to ensuring the safety of patients, and duodenoscopes have historically presented one of the greatest risks to patients in healthcare facilities. By using hydrogen peroxide gas plasma sterilization to reprocess duodenoscopes, we are achieving an increased level of certainty of sterility for healthcare professionals.”
“The use of hydrogen peroxide gas plasma represents a significant shift in making it the gold standard of sterilization for duodenoscopes and thereby improving safety for patients, technicians, and the environment,” said Ivan Salgo, MD, Chief Medical & Scientific Officer at ASP. “The ULTRA GI™ Cycle sets a new benchmark for the entire industry on sterilization and environmental safety and will give healthcare professionals and their patients a heightened level of assurance that the duodenoscopes used are now being sterilized in a safe and effective way.”
About Advanced Sterilization Products (ASP)
Advanced Sterilization Products (ASP) has a long track record of designing and delivering innovative infection prevention solutions that dramatically raise the level of health care and safety for those who matter most. Our pioneering technology, global distribution and established leadership position enable us to simplify the process of buying and operating infection prevention products and services every day for thousands of medical facilities around the world. This enables our customers to focus on what they do best – preventing infection and saving lives. For more information, please visit www.asp.com.

### CS Week Giveaway Offered by Healthmark, A Getinge Company!
Healthmark, A Getinge Company has announced that they are giving away a bottle of XEN Xcelerate during SP week (October 13-19) to celebrate and recognize all the hard-working Healthcare Professions that are dedicated to patient safety all year round! To receive your complimentary bottle, click on this link below: https://www.hmark.com/xen-xcelerate-complimentary-bottle-request/ XEN Xcelerate is a ready-to-use foam spray that requires no dilution, maximizing usability when time is tight for healthcare professionals. It kickstarts cleaning at the point of use, allowing the XEN sterile processing workflow to begin before instruments even reach the SPD, providing your staff with a better starting point in the manual sinks. Chemically designed to support the cycles of washer-disinfectors, Xcelerate is applied in the OR or the ED to begin the process of decontamination. Early treatment reduces the risk of biofilm formation and helps prevent corrosion. Hurry, this limited time offer and only available while supplies last!

### Study: Common Meds May Be Dangerous During Upper Endoscopy
Patients who take a class of widely prescribed medications to manage diabetes and obesity may require extra preparations before undergoing upper endoscopy procedures, according to a new Cedars-Sinai study.
The drugs, known as glucagon-like peptide-1 receptor agonists (GLP-1RAs), are marketed under many brand names. They work by stimulating insulin secretion, slowing down food leaving the stomach, and causing a delay in gastric emptying. As a result, the drugs may help Type 2 diabetes patients manage their blood sugar and help patients with obesity to lose weight.
According to the study, published Oct. 1 in the journal JAMA Network Open, these medications may also lead to problems during upper endoscopies.
Researchers found that patients who regularly took GLP-1RAs were significantly more likely to retain food in their stomachs during the procedure than were patients who did not take the drugs. Food retention can raise the risk of aspiration, a rare but serious complication of surgeries in which stomach contents are introduced into the lungs while a patient is under sedation.
The researchers found that even though patients in the study, as instructed, stopped taking the GLP-1RAs a week before their upper endoscopies, they were still more likely to retain food than those who did not take these drugs.
"The effects of the GLP-1RA drugs appeared to persist even when patients were asked to stop taking them a week before the procedure," said endocrinologist Ruchi Mathur, MD, professor of Medicine, director of Clinical Research and Clinical Operations for Medically Associated Science and Technology at Cedars-Sinai and the study's corresponding author. She added that although aspiration was not detected in any of the patients, food retention can make aspiration more likely.
A total of 70 individuals taking GLP-1RAs and 139 controls were included in the study.
Results showed that 17% of patients on the drugs who underwent upper endoscopy alone showed food retention, compared with none of the controls. They also observed that patients who underwent both a colonoscopy and an upper endoscopy on the same day, requiring a 24-hour clear liquid and bowel preparation protocol, showed no food retention in either the GLP-1RA group or the controls. "This protective effect against food retention may be due to the preparation typically required for colonoscopies, as opposed to upper endoscopies," Mathur said.
The researchers also found a clear association between GLP-1RA use, which can sometimes produce constipation as a side effect, and unsatisfactory bowel preparation for colonoscopies. Inadequate bowel preparation may contribute to missed lesions, patient dissatisfaction, and cancellation of the procedure.
"Overall, our results support the value of individualizing recommendations for patients and having risk-benefit discussions for patients on these drugs," Mathur said. "Any patients using a GLP-1RA drug should be sure to inform their physicians and anesthesiologists before undergoing gastrointestinal procedures."

### Is Abdominal Pain a Symptom of Colon Cancer?
Colon cancer involves the large intestine. It is prevalent globally and is risky if it is not detected early. Abdominal pain is one potential symptom of colon cancer. But how do we know that this pain is caused by colon cancer?This investigates whether abdominal pain may be due to colon cancer. We will also consider other symptoms and why it should be detected early.What is Colon Cancer?Colon cancer begins when abnormal cells in the colon begin to grow in an uncontrollable manner. These cells can, over time, develop into polyps or tumors. If left untreated, they can become malignant. The precise cause of colon cancer is unknown, but various factors contribute to the risk. These include genetics, age, lifestyle, and diet.Colon cancer symptoms tend not to surface until the condition is more established. That's why early diagnosis is essential for treatment.Is Abdominal Pain a Sign of Colon Cancer?Yes, abdominal pain may be a symptom of colon cancer. But abdominal pain is not necessarily caused by cancer. Most common conditions such as gas, constipation, or indigestion can lead to abdominal discomfort. But if the pain is recurring and there is no explanation for it, it must be taken seriously.In cancer of the colon, belly pain may occur when a tumor clogs part of the intestine. The pain may be crampy, bloated, or uncomfortable. As the illness gets worse, the pain becomes more severe and frequent.Types of Abdominal Pain in Colon CancerAbdominal pain associated with colon cancer may be of different types. It is dependent on the tumor location and disease stage. The following are some common types of pain:Cramping and Bloating: They are initial signs. They are usually confused with gas or indigestion. If they persist for a long duration, it may be due to colon cancer.Sharp Pain: An enlarging tumor can obstruct the bowel, leading to sharp, severe pain. This can be a sign of an obstruction of the bowel. It is an emergency situation that requires medical attention.Widespread Discomfort: The discomfort may not remain in one area. Rather, it could move throughout the abdomen, which suggests the condition is spreading.Other Symptoms of Colon CancerIt usually occurs along with other symptoms. Knowing the entire list of colon cancer symptoms aids in early detection:Changes in Bowel Habits: Constipation, diarrhea, or alternate constipation and diarrhea. When these last for several weeks, it may be due to colon cancer.Blood in the Stool: Blood in the stool or rectal bleeding is a warning sign. Blood may be bright red or dark, depending on the location of the bleeding.Unexplained Weight Loss: Weight loss without trying is another symptom. Colon cancer can cause the body to do extra work, resulting in weight loss.Fatigue: Cancer can drain your energy, causing fatigue. In colon cancer, this could also be due to bleeding, which can lead to anemia.Incomplete Bowel Movements: Some people with colon cancer feel like they still need to go to the bathroom even after a bowel movement. This discomfort is another key sign.Narrow Stools: If stools feel narrower than normal, and this persists for a few days, it may be a sign of a colon tumor.When to See a Doctor?Some pain in the belly is probably not a cause for concern. But pain that happens over and over should be examined.Changes in bowel habits without a reasonBlood in the stoolUnexpected weight lossPersistent tirednessThe sooner colon cancer is detected, the better are the chances for effective treatment. Routine screening tests can detect it early.Risk Factors for Colon CancerThese are:Age: Individuals above the age of 50 have a greater risk of colon cancer.Family History: When there is colon cancer in your family, your risk increases.Diet: Red meat-rich and low-fruit and low-vegetable diets are associated with colon cancer.Smoking and Alcohol: Smoking and excessive alcohol consumption can increase the risk of colon cancer.Obesity: Being overweight or inactive also raises your risk of colon cancer.How is Colon Cancer Diagnosed?If you have symptoms of colon cancer, your physician may recommend a number of tests:Colonoscopy: This procedure lets the physician view your colon to check for polyps or tumors.CT Scan: A scan can determine whether cancer has spread outside the colon.Biopsy: A tissue sample may be obtained to find out if a tumor is cancerous.Stool Tests: Certain stool tests are able to identify blood, which can be an indication of colon cancer.Treatment for Colon CancerIf it is found that one has colon cancer, the treatment process is based on the stage of the disease. Treatment options include:Surgery: Surgery is commonly the initial treatment of colon cancer. It involves removal of the tumor and surrounding affected tissues.Chemotherapy: Chemotherapy involves using medications to destroy cancer cells or prevent them from multiplying. It is typically administered when cancer has spread.Radiation Therapy: Radiation employs high-energy beams to kill cancer cells and reduce tumors.Targeted Therapy: These drugs attack specific molecules that enable cancer cells to proliferate.Can Colon Cancer Be Prevented?Although colon cancer can't always be avoided, you can do some things to reduce your risk:Regular Screenings: Colon cancer screenings may detect the disease in its early stages or even prevent it by removing polyps.Healthy Diet: Increasing fruit, vegetable, and whole grain consumption can lower your risk.Stay Active: Exercise regularly to help keep you at a healthy weight and decrease your risk.Don't Smoke and Drink: Stopping smoking and cutting down on drinking decreases the chances of colon cancer and other diseases.Pain in the stomach is one symptom of colon cancer, but it is not a solitary indicator. If you get persistent pain combined with other signs, such as blood in your stool or losing weight, then you should go to the doctor. Colon cancer can be diagnosed early and cured if detected on time.

### Bowel Preps 101: Advice for a Successful Colonoscopy
A colonoscopy is a crucial medical test that helps doctors check for issues in the colon and rectum, such as polyps or signs of cancer. However, for the procedure to be successful, the colon needs to be thoroughly cleaned beforehand. This cleaning process is called "bowel prep." We’ll explain why bowel preps are so important, how they work, and what you should know about them.
What Are Bowel Preps?
Bowel preps are a combination of diet changes and medications that are used to clear out your colon before a colonoscopy. The aim is to remove any waste from your intestines, so doctors can get a clear view inside the colon. A clean colon allows doctors to spot any problems more easily.
Why Are Bowel Preps Important?
1. Clearer View for Doctors
The main reason for bowel preps is to make sure the colon is clean. If there is leftover stool in the colon, it can block the doctor’s view, making it difficult to see the lining of the colon. This could lead to important issues being missed during the colonoscopy.
2. Better and Accurate Diagnosis
A clean colon is essential for an accurate diagnosis. Leftover stool can hide abnormalities, such as polyps or other concerns. If the colon isn’t cleaned properly, doctors may not be able to detect potential problems, which could lead to a wrong or incomplete diagnosis. A good bowel prep ensures that doctors can examine the entire colon thoroughly.
3. Shorter Procedure Time
When the colon is well-prepped and clean, the doctor can perform the colonoscopy faster. This is because they won’t have to spend extra time cleaning out waste during the procedure. A clean colon helps doctors focus on looking for abnormalities, which speeds up the process.
4. Avoiding a Repeat Colonoscopy
If your colon isn’t properly cleaned before the colonoscopy, you may have to repeat the entire process. This can be both uncomfortable and inconvenient. To avoid having to do the test again, it’s important to follow the bowel prep instructions carefully and ensure the colon is as clean as possible.
How Do Bowel Preps Work?
1. Diet Adjustments
A few days before the colonoscopy, you will need to make changes to your diet. Typically, this involves avoiding solid foods and sticking to clear liquids, such as broth, clear juices, and water. This helps to reduce the amount of solid waste in your colon, making the cleaning process easier.
2. Taking Medication
The most important part of the bowel prep process is taking medication that helps flush out waste from your colon. These medications usually come in the form of a liquid solution or pills. You will need to drink or take these as instructed by your doctor, which will cause frequent bowel movements to clear out your colon.
3. Staying Hydrated
Because the bowel prep medication can lead to dehydration, it’s essential to drink plenty of clear fluids during the process. Staying hydrated will help keep you comfortable and aid in the cleaning process.
4. Following the Instructions
Your doctor will give you specific instructions on how to complete the bowel prep, including when to start the diet changes, when to take the medication, and how much fluid to drink. It’s very important to follow these instructions exactly to ensure your colon is properly cleaned.
Tips for a Successful Bowel Prep
1. Stick to the Plan
Make sure to follow the instructions given by your doctor closely. Any changes to the diet or medication plan can affect how well your colon is cleaned.
2. Plan Ahead
The bowel prep process can be tiring, and you’ll likely need to use the bathroom frequently. It’s a good idea to set aside time for the prep when you don’t have any important activities planned. This will give you a chance to rest and complete the prep without any interruptions.
3. Drink Lots of Fluids
Keeping yourself hydrated is key during the bowel prep process. Drinking plenty of clear liquids will help flush out your colon and prevent dehydration.
4. Use Comfort Measures
The bowel prep process can sometimes be uncomfortable due to the frequent trips to the bathroom. Using moist wipes instead of regular toilet paper can help prevent irritation, and applying a barrier cream to the skin can reduce discomfort. Make sure you have a comfortable place to rest while going through the prep.
5. Reach Out for Help
If you run into any issues or have questions about the bowel prep, don’t hesitate to contact your doctor. They can offer advice on how to handle any challenges, such as difficulty taking the medication or feeling dehydrated.
Bowel preps play a vital role in ensuring a successful colonoscopy. By cleaning out the colon, bowel preps allow doctors to clearly see any potential issues and make accurate diagnoses. Although the process can be uncomfortable, the benefits of a properly cleaned colon far outweigh the challenges. Following the instructions carefully and staying hydrated will help make the colonoscopy as smooth and effective as possible. By completing the prep properly, you can avoid the need for repeat procedures and ensure a faster, more accurate colonoscopy experience.

### Genetic Testing for Colon Cancer: How It Works and What It Reveals
Colon cancer is common worldwide. Early detection improves treatment outcomes. A genetic test for colon cancer helps identify your risk and aids in personalized care. Here, we’ll explain how it works, what it reveals, and who should consider getting tested.
What is a Genetic Test for Colon Cancer?
A genetic test for colon cancer looks for mutations in specific genes. These genes, like APC, MLH1, and MSH2, are linked to colon cancer. The test identifies changes in your DNA that may increase your risk of developing the disease. If mutations are found, doctors can suggest steps to manage or reduce the risk.
How Does a Genetic Test for Colon Cancer Work?
The test is simple and usually requires a blood, saliva, or tissue sample. Here's how it works:
 	Consultation: You meet with a genetic counselor or doctor. They discuss your family and personal history of colon cancer.
 	Sample Collection: A sample of blood, saliva, or tissue is taken.
 	Lab Analysis: Technicians look for genetic mutations in your sample.
 	Results: The results are shared with your doctor, who explains what they mean.
The procedure is painless, and results typically take a few weeks.
What Does a Genetic Test for Colon Cancer Reveal?
A genetic test for colon cancer can reveal:
 	Genetic Mutations: It identifies changes in genes that increase cancer risk.
 	Cancer Risk: If mutations are found, it may mean a higher risk of colon cancer. For instance, Lynch syndrome is a condition caused by gene mutations that increase colon cancer risk.
 	Risk of Other Cancers: Mutations linked to colon cancer can also raise the risk of other cancers, like ovarian or stomach cancer.
 	Family Risk: The test shows if your family members might also be at risk.
Who Should Consider a Genetic Test for Colon Cancer?
Not everyone needs a genetic test for colon cancer.
 	A family history of colon cancer.
 	A relative who had colon cancer before age 50.
 	Known genetic mutations like Lynch syndrome or familial adenomatous polyposis (FAP).
 	A history of other cancers linked to colon cancer genes.
If any of these apply to you, your doctor might suggest getting tested.
What Happens After the Test?
After the test, your doctor will explain the results. Possible outcomes include:
 	Positive Result: A mutation is found, meaning higher cancer risk. Your doctor will suggest ways to manage or lower this risk, like regular screenings or preventive surgery.
 	Negative Result: No mutations were found. This means your risk is lower, but you should still follow regular screening guidelines.
 	Uncertain Result: The test finds a genetic change, but it’s unclear if it increases cancer risk. Your doctor may recommend more testing.
Benefits of a Genetic Test for Colon Cancer
A genetic test offers many benefits:
 	Early Detection: It can lead to earlier and more frequent cancer screenings.
 	Personalized Care: Doctors can develop a treatment plan based on your genetic risk.
 	Family Planning: If a mutation is found, relatives can also be tested.
 	Informed Decisions: Knowing your risk allows you to take preventive actions.
Risks and Limitations of Genetic Testing
Though helpful, a genetic test for colon cancer has some risks and limitations:
 	Emotional Impact: Finding out you have a higher risk can be stressful.
 	Uncertainty: Not all genetic changes are understood. Some results may be unclear.
 	Privacy Concerns: Some people worry about how their genetic information will be used. Laws protect your privacy in many countries.
What to Do if You Have a High Genetic Risk
If your genetic test shows a high risk, you can take steps to protect yourself:
 	Regular Screenings: Your doctor may suggest frequent colonoscopies.
 	Lifestyle Changes: Eating healthy, exercising, and not smoking can lower your risk.
 	Preventive Surgery: In extreme cases, doctors may recommend surgery to reduce your risk.
 	Medication: Certain drugs may help lower the chances of getting colon cancer.
A genetic test is a valuable tool that reveals important details about your cancer risk. It helps doctors create personalized treatment plans and allows you to take steps to protect your health. While not everyone needs this test, it’s highly beneficial for those with a family history of colon cancer or related cancers.
If you think a genetic test for colon cancer is right for you, talk to your doctor or a genetic counselor. They can guide you through the process and help you take the necessary steps to stay healthy.

### The Importance of Regular Endoscopic Screenings
Endoscopy is a vital medical procedure that allows doctors to visually examine the interior of a patient's body using an endoscope—a flexible tube with a light and camera attached. Regular endoscopic screenings are crucial in maintaining good health, particularly for individuals at risk for gastrointestinal (GI) diseases, cancers, and other conditions. These screenings can detect abnormalities early, leading to timely intervention and improved outcomes. Here we’ll explore the importance of regular endoscopic screenings, their role in preventive healthcare, and guidelines for who should consider them.
Early Detection of Gastrointestinal Diseases
One of the primary reasons for undergoing regular endoscopic screenings is the early detection of gastrointestinal diseases. Conditions such as peptic ulcers, inflammatory bowel disease (IBD), celiac disease, and Barrett's esophagus can be identified during an endoscopy, often before symptoms become severe. Early diagnosis enables timely treatment, lowering the chance of complications and enhancing patients' quality of life.
For example, in the case of Barrett's esophagus—a condition in which the esophagus lining is damaged by stomach acid—regular endoscopic monitoring is essential. This condition can lead to esophageal cancer if left untreated. With regular screenings, changes in the esophagus can be detected early, and appropriate interventions, such as medication or surgery, can be implemented to prevent cancer development.
Crucial in Cancer Prevention and Early Diagnosis
Endoscopic screenings play a significant role in cancer prevention, particularly for cancers of the digestive system, such as colorectal, stomach, and esophageal cancers. Colonoscopy, a type of endoscopy that examines the large intestine, is considered the gold standard for colorectal cancer screening. During a colonoscopy, doctors can detect and remove precancerous polyps, effectively preventing the development of colorectal cancer.
Stomach cancer, another life-threatening disease, can also be detected early through endoscopic screenings. Gastric endoscopy, or gastroscopy, allows doctors to identify precancerous lesions and early-stage cancers in the stomach lining. Early detection is critical because stomach cancer often does not cause noticeable symptoms until it is advanced, making it harder to treat.
In the case of esophageal cancer, endoscopic screening is vital for individuals with risk factors such as chronic gastroesophageal reflux disease (GERD), smoking, or heavy alcohol use. Regular screenings can detect changes in the esophagus lining, allowing for early intervention and increasing the chances of successful treatment.
Guidelines and Recommendations for Endoscopic Screenings
The frequency and type of endoscopic screening recommended for an individual depend on various factors, including age, medical history, and risk factors. Here are some general guidelines:
 	Colonoscopy: It is generally recommended that adults begin regular colonoscopy screenings at age 45, with subsequent screenings every 10 years if no abnormalities are found. Individuals with a family history of colorectal cancer or other risk factors may need to start screenings earlier and have them more frequently.
 	Gastroscopy: Individuals with symptoms such as persistent heartburn, difficulty swallowing, or unexplained weight loss may be advised to undergo a gastroscopy. Those with a history of stomach ulcers, GERD, or family history of stomach cancer should also consider regular screenings.
 	Endoscopic Ultrasound (EUS): This type of endoscopy is often recommended for individuals at high risk of pancreatic or esophageal cancer. It can provide detailed images of the digestive tract and surrounding tissues, aiding in the early detection of tumors.
 	Capsule Endoscopy: For patients with unexplained gastrointestinal bleeding or suspected small bowel disease, capsule endoscopy—where a small, pill-sized camera is swallowed—may be recommended. This allows for detailed imaging of the small intestine, which is difficult to reach with traditional endoscopy.
The Role of Endoscopy in Preventive Healthcare
Regular endoscopic screenings are not just about detecting diseases but also about preventive healthcare. By identifying and addressing issues before they escalate, endoscopic screenings can prevent serious health complications. This proactive approach to healthcare aligns with the broader movement towards preventive medicine, where the focus is on maintaining health rather than just treating disease.
Moreover, endoscopic screenings provide peace of mind. Knowing that potential issues are being monitored and addressed can reduce anxiety and stress, contributing to overall well-being. For individuals with a family history of GI diseases or cancer, regular screenings can be particularly reassuring.
Conclusion
The importance of regular endoscopic screenings cannot be overstated. These procedures are essential tools in the early detection and prevention of gastrointestinal diseases and cancers. By following recommended screening guidelines and working closely with healthcare providers, individuals can significantly reduce their risk of serious health issues. Endoscopic screenings are a proactive step towards better health, providing valuable insights into the body’s inner workings and helping to ensure a longer, healthier life.

### Health-Worker Burnout
It’s a safe assumption that most people who go into healthcare enter the field to help people. They know the profession is difficult, high pressure, hard on the body, and that there are occupational risks. However, the average healthcare worker probably doesn’t start their career thinking they’ll end up overwhelmed and overworked, and often feeling unsupported. And yet, unfortunately, that’s where a great many medical professionals have arrived.
The result: Burnout.
Recently, United States Surgeon General Dr. Vivek Murthy issued a surgeon general’s advisory highlighting the urgent need to address the health-worker burnout crisis across the country. Health workers—including physicians, nurses, community and public-health workers, nursing aides, etc.— have long faced systemic challenges, such as burnout, in the healthcare system. The COVID-19 pandemic further exacerbated burnout, with many workers risking and sacrificing their own lives in the service of others while responding to the public health crisis.
The surgeon general’s advisory addressing health-worker burnout lays out recommendations to address the factors underpinning the crisis, improve health-worker well-being, and strengthen the nation’s public health infrastructure.
“At the height of the COVID-19 pandemic, and time and time again since, we’ve turned to our health workers to keep us safe, to comfort us, and to help us heal,” said U.S. Secretary of Health and Human Services Xavier Becerra. “We owe all health workers—from doctors to hospital custodial staff—an enormous debt. And as we can clearly see and hear throughout this surgeon general’s advisory, they’re telling us what our gratitude needs to look like: real support and systemic change that allows them to continue serving to the best of their abilities.”
The nation’s health depends on the well-being of our health workforce, said Surgeon General Murthy in his advisory. “Confronting the long-standing drivers of burnout among our health workers must be a top national priority. COVID- 19 has been a uniquely traumatic experience for the health workforce and for their families, pushing them past their breaking point. Now, we owe them a debt of gratitude and action. And if we fail to act, we will place our nation’s health at risk. This surgeon general’s advisory outlines how we can all help heal those who have sacrificed so much to help us heal.”
Even before the COVID-19 pandemic, health workers were experiencing alarming levels of burnout, broadly defined as a state of emotional exhaustion, depersonalization, and low sense of personal accomplishment at work. Burnout can also be associated with mental-health challenges such as anxiety and depression.
In 2019, the National Academy of Medicine (NAM) reported that burnout had reached “crisis” levels, with up to 54% of nurses and physicians, and up to 60% of medical students and residents, suffering from burnout. The pandemic has since affected the mental health of health workers nationwide, with more than 50% of public health workers reporting symptoms of at least one mental-health condition, such as anxiety and depression, and increased levels of post-traumatic stress disorder (PTSD).
Health-worker burnout not only harms individual workers, but also threatens the nation’s public health infrastructure. Already, Americans are feeling the impact of staffing shortages across the health system in hospitals, primary care clinics, and public health departments. With more than half a million registered nurses anticipated to retire by the end of 2022, the U.S. Bureau of Labor Statistics projects the need for 1.1 million new registered nurses across the U.S. Further, within the next five years, the country faces a projected national shortage of more than 3 million low-wage health workers.
The Association of American Medical Colleges (AAMC) projects that physician demand will continue to grow faster than supply, with the most alarming gaps occurring in primary care. Health-worker burnout affects the public’s ability to get routine preventive and emergency care, and our country’s ability to respond to public health emergencies.
Consider the following from a U.S. Department of Health and Human Services webpage: “The realities of our healthcare system are driving many health workers to burnout. They are at an increased risk for mental-health challenges and choosing to leave the health workforce early. They work in distressing environments that strain their physical, emotional, and psychological well-being. This will make it harder for patients to get care when they need it.”
HHS wrote, “Workplace systems cause burnout among health workers. There are a range of societal, cultural, structural, and organizational factors that contribute to burnout among health workers. Some examples include: excessive workloads, administrative burdens, limited say in scheduling, and lack of organizational support.”
According to Dr. Murthy, we should all be on the lookout for detecting burnout in our colleagues and the medical professionals we know in our personal lives. “Check in with the health workers you know,” Dr. Murthy advised in a Q&A on the HHS website. “Help them stay connected. Ask them how they are doing and how you can help them. Pay attention to warning signs that indicate that they may need professional support from a mental health provider. Common behaviors to watch out for are: increased irritability, withdrawal from friends and family, impaired judgment, excessive alcohol or substance use, reduced ability to manage emotions and impulses, and decreased personal hygiene.”
To help address burnout on a wide scale, topline recommen- dations from the surgeon general’s advisory include:
 	Transform workplace culture to empower health workers and be responsive to their voices and needs. We can begin by listening to health workers and seeking their involvement to improve processes, workflows and organizational culture.
 	Eliminate punitive policies for seeking mental-health and substance-use-disorder care.
 	Ensure that on-demand counseling and after-work care are more accessible to health workers to promote and preserve their well-being.
 	Protect the health, safety and well-being of all health workers.Provide living wages, paid sick and family leave, rest breaks, evaluation of workloads and working hours, educational debt support, and family-friendly policies (including childcare and care for older adults) for all health workers.
 	Ensure adequate staffing—including surge capacity for public health emergencies—that is representative of the communities they serve. This is critical to protect and sustain health workers and communities.
 	Organizations, communities and policies must prioritize protecting health workers from workplace violence and ensure that they have sufficient personal protective equipment. In a national survey among health workers in mid-2021, eight out of 10 experienced at least one type of workplace violence during the pandemic, with two-thirds having been verbally threatened, and one-third of nurses reporting an increase in violence compared to the previous year.
 	Reduce administrative burdens to help health workers have productive time with patients, communities and colleagues. One study showed that on average, for every hour of direct patient care, a primary care provider will spend two hours a day on administrative tasks. That is time that could be spent with patients, in the community, and building relationships with colleagues, which is essential to strengthening the health and well-being of both health workers and
 	Prioritize social connection and community as a core value of the healthcare system. This enhances job fulfillment, protects against loneliness and isolation, and ultimately improves the quality of patient care. Include peer and team-based models of care to strengthen collaboration and create opportunities for social support and community.
 	Invest in public health and our public health
 	Diversify and expand the public health workforce and improve disease surveillance systems to help address social determinants of health and health inequities, counter health misinformation, and strengthen partnerships across clinical and community settings.
Until we address at least some of the above problems, we can expect healthcare worker burnout to increase and patient satisfaction to move in the opposite direction.
Most of the above article is part of a recent surgeon general’s advisory. These advisories are public statements that call the American people’s attention to a public health issue and provide recommendations for how it should be addressed. Advisories are reserved for significant public-health challenges that need immediate attention. To view the advisory in full, visit https://www.hhs.gov/surgeongeneral/priorities/health-worker-burnout/index.html

### Short-Bowel Syndrome
Oh, the small intestine. It just doesn’t get any press.
Unlike  the  more  glamorous  colon  (“Don’t  forget  your colonoscopy!”) or the stomach (“Doc, the pain just won’t go away”), the small intestine just quietly goes about its job, somewhat like the second assistant director on a film: unsung, but you can’t get the job done without her.
Until something goes wrong.
In short bowel syndrome (SBS), something has gone radically wrong: The small intestine can no longer do its job. According to the Short Bowel Syndrome Foundation, the condition occurs when “parts of the intestine are removed surgically,” making it more difficult for the remaining intestine to process food. In the journal Nutrition in Clinical Practice, Loris Pironi stated that the syndrome defines “the clinical feature associated with a remaining small bowel in continuity of less than 200 centimeters from the ligament of Treitz.”
This disorder can manifest a host of uncomfortable and debilitating symptoms, including bloating and flatulence, vomiting, food allergies/sensitivities, cramps and heartburn, sleep deprivation and fatigue, irregular bowel habits, and difficulty maintaining weight, among others.
A severe potential effect of SBS is chronic intestinal failure (CIF), leading to symptoms such as diarrhea, electrolyte disturbances, malnutrition and dehydration. Pironi wrote that CIF is “defined as the ‘reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation (IVS) is required to maintain health and/or growth’ in a metabolically stable patient.” This is known as parenteral nutrition, in which the patient receives part or all their nutrition through an IV, bypassing the digestive system.
When the lack of absorption isn’t as severe, the patient may be classified with intestinal insufficiency (II), or intestinal deficiency (ID).
While SBS is relatively rare, affecting an estimated 10,000 to 20,000 people in the United States, the past 40 years have seen the number of cases double. Endo, et al., wrote in the journal Regenerative Therapy, “Treatment for SBS is mainly supportive, consisting of supplementation, prevention and treatment of complications, and promotion of intestinal adaptation. While development of parenteral nutrition  and  drugs  promoting  intestinal adaptation has improved clinical outcomes, the prognosis of patients with SBS remains poor. Intestinal transplantation is the only curative therapy, but its outcome is unsatisfactory.”
The Short Bowel Syndrome Foundation has resources to help patients cope with the nutritional demands of their condition.
Deep in the Weeds
In a CME Outfitters webinar, Miguel Regueiro, M.D., AGAF, FACG, FACP, chair of the Digestive Disease and Surgery Institute at the Cleveland Clinic, discussed with Doctors Kishore R. Iyer and Donald F. Kirby the challenges of SBS and how to create a “medical neighborhood” to help patients cope with—and thrive in spite of—the disorder.
There are three types of SBS according to anatomical criteria. Type 1 is end-jejunostomy, which  is  the  most  severe,  according  to Donald F. Kirby, M.D., FACP, FACN, FACG, AGAF, FASPEN, CNSC, CPNS, the medical director of the intestinal transplant program and professor of medicine at the Cleveland Clinic. “It has the worst prognosis because it has the shortest amount of surface area,” he said. Indicators include rapid transit, acid hypersecretion, poor adaptation, large fluid losses, and malabsorption.
The most common is Type 2 SBS, jejuno- colonic,  which  has  rapid  transit,  poor adaptation, B12 and bile salt malabsorption, and variable calorie and fluid absorption. “To really stay off parenteral nutrition in this type, you need more than 65 centimeters of jejunum to at least half or more of colon,” Kirby said.
Jejunoileo-colonic, Type 3, has adequate absorption until about 75% resected. It also has good adaptation and slower transit. But although it offers the best prognosis, it’s uncommon—only about 9% of patients are Type 3. They do well, Kirby said, because “they’ve got that ileocecal valve … These patients are the easier ones to rehabilitate and get off parenteral nutrition.” However, adaptation can take two to three years, so patience is critical.
The disease is tough enough to deal with on the day to day, but according to Kishore R. Iyer, MBBS, FRCS (Eng), FACS, professor of surgery and pediatrics at Mount Sinai Medical Center in New York City, it gets really difficult when patients encounter social situations. “Think about one thing any one of us does socially that does not involve food and drink. So for patients living with this disease, it is really quite devastating at many levels,” he said. Worries about the stoma bag leaking, embarrassing digestive noises or urgency to go to the toilet can substantially impair quality of life for patients.
And while total parenteral nutrition (TPN) is lifesaving, it can also impose burdens, especially  if  patients  are  infusing  their nutrition at night: If the machine’s alarm is constantly going off, and patients have to wake up constantly, this will interfere with their sleep cycle. If you’ve ever had a colicky child or a medical condition that constantly rouses you, you know what it can do to your daily productivity.
Kirby concurred. “Being on home parenteral nutrition is harder than being on dialysis,” he said. “You go to a dialysis center, you give them an arm, they hook you up, you sit there, watch TV for three, four hours, and then you go home, eat, drink, be merry.
“For TPN, you’ve got to take the bag out of the refrigerator, you need to let it get to room temperature. You then may have to add a couple of additives, and then you put it up on the pole, and then you prime the pump, and then you set it up and let it go, and then the pump beeps in the middle of the night, and then you’re infusing things at 200 to 300 milliliters per hour, so what does  that  mean?  Well,  everybody’s going to get up and start peeing in the middle of the night, so nobody gets a good night’s rest. If you can give them a night off, you have suddenly made a best friend. It’s really important to realize the burden on these patients.”
Partial parenteral nutrition can be paired with regular eating, but patients on TPN should avoid eating. Some report hunger cravings, while others do not. So much depends on the patient, the amount of digestive tract, and the team.
Creating an Interdisciplinary Team
Patients benefit when all their healthcare professionals are on the same page.
The key to facilitating communication, whether  in  clinical  practice  or  research, according to Pironi, is careful and “homogenous” categorization of the disease. This categorization may include  anatomy (e.g.,  length  of  bowel), evolutionary  factors  (maintenance  phases), pathophysiological factors (whether there is a “colon in continuity”), clinical factors (level of malabsorption), and severity of chronic intestinal failure (CIF).
Kirby said the first place to start in achieving an early and accurate diagnosis is by taking a comprehensive  and  accurate  medical  history. This may require some digging. When surgeons measure the amount of remaining small bowel and make a note of it, that’s very helpful for members of the medical team as they follow up and create a treatment plan. Blood work and fecal fat testing reveal a lot of information, but endoscopy and colonoscopy are important, too, Kirby said, especially if you’re dealing with patients who might have mucosal disease, as this can affect nutrient absorption.
Iyer said that a good intestinal rehabilitation team should have “medical expertise in the form of a gastroenterologist, [and] ideally, a hepatologist as well. There should be a surgeon with an interest in intestinal failure. We also have an intestinal transplant program. Our intestinal transplant program rests squarely within the intestinal rehab program. We view intestine transplant as just one extreme piece of the intestinal rehabilitation team. But that’s only the physicians.”
Kirby added that one of the team leaders could be the gastroenterologist or pediatric gastroenterologist,  but  this  depends  on  the program  you’re  working  with.  “Many  home parenteral nutrition programs in the U.S. … have an endocrinologist, or maybe it’s embedded in surgery.” He works closely with transplant, reconstructive and general surgeons, depending on whether the patient needs a feeding tube, assessment or reconstructive surgery. “We may have to work with intensivists when our patients are admitted with sepsis from another catheter infection … and we have excellent interventional radiologists that helped us get the line in, keep the line in, and maintenance of that line, which is absolutely imperative.” And of course, nurses who help with line care and ostomy care.
One factor teams often overlook is involving the health insurance company early in the process. Other team members critical to rehabilitation include those with expertise in nutrition, dietitians and nutritionists, Iyer said. Incorporate someone with expertise in medical management. You’ll likely also need social workers, pharmacists, infectious disease specialists and radiologists. The team may be large, but that’s necessary to provide the patient—and the patient’s family—with the best possible care.
So is education. Kirby includes medical educators on his team. He provides an educational series for parenteral patients, and he goes so far as to have them sign a patient agreement, acknowledging they’ve seen it.
Pharmacists do their part on the team, prepping the TPN and flagging potential drug interactions and drug/nutrient interactions, which can manifest quickly and may have lethal consequences. Tomczak, Stawny and Jelinska wrote, “In  addition  to  drug  incompatibility,  other  intravenous medication administration errors may affect a patient’s condition, including the risk of death and the increased cost of medical care resulting from a prolonged stay at the hospital.” The standardization of PN admixtures has helped reduce medical errors, but it’s still important to have a pharmacist on board.
And parenteral feeding can induce complications, including overfeeding, sepsis, GI atrophy and fluctuating blood sugar levels. On the long term, parenteral feeding can cause a form of liver disease, gallbladder problems, and demineralization of bones.
Nutrition assistance and counseling is critical to patients. Kirby called the registered dietitians at his facility “probably the most important member[s] of my team.” While it’s easy to set down a bunch of rules about what a patient can and cannot eat, the dietitian personalizes it for each patient, depending on multiple needs. “We try to get into their lives and figure out the best diet we can for them,” he said.
According to Kirby, the best place to start when it comes to diet is by determining how much colon a patient has left. “If they have a colon, you’re going to have to put them on a lower fat diet than if they go straight to an ileostomy or a jejunostomy.” Key to success is keeping patients on small meals: five or six smaller meals or light snacks in a day. “We don’t want to overload their surface area,” Kirby said. He advises that patients eat slowly, avoiding simple carbohydrates and simple sugars, as well as limiting lactose.
Avoiding sorbitol is important to limiting diarrhea, and even too much water can be problematic. Kirby recommended oral rehydration solutions—often used for patients where intravenous fluids are unavailable or impractical—and again, slow consumption.
To help deal with practical considerations like home envi- ronment, needs and finances, Kirby ensures social workers are a part of the team. He also includes a psychologist; pa- tients and their families can become depressed or anxious about the patient’s situation. “This affects every member of the family,” Kirby said. “Sometimes [even] the pets.”
Iyer said that a good intestinal rehabilitation team should have “medical expertise in the form of a gastroenterologist, [and] ideally, a hepatologist as well.
In  pediatrics,  Iyer said,  team  members  should  include occupational and behavioral therapists, as well as people with  expertise  in  speech  and  swallowing  mechanisms. The composition of the team will depend on the type of diagnosis and needs of the patient. Pediatric cases may include experts in behavioral health, dietitian, nutrition, medicine, surgery and radiology. Kirby said that probably more important for pediatrics is having a speech pathologist. The tiniest patients may never have been taught to eat; some don’t even have a suck reflex.
The importance of child and family support for pediatric patients cannot be overstated, so Kirby includes a child life specialist.
Pediatrics can be tricky. “For the patient … we want to achieve freedom from parenteral nutrition to the extent that’s possible,” Iyer said. “That should be goal one.” For some patients, this is impossible. So goal two is “freedom from complications.”
The third goal is improving quality of life. Iyer’s team works to understand, empathize and see how they can help. “The therapy itself is burdensome; the disease is burdensome,” Iyer said. “It’s not for me to comment on a patient’s quality of life. I need to listen and hear from the patient and his or her family—what is their quality of life, and is there something I can help with?” It might be as simple as recommending the patient carry their parenteral nutrition bag in a backpack during the day so they can get a better night’s sleep.
“This really takes a village,” Kirby said. “To be successful, you need to have a team of people [who] are interested, dedicated and want to work together.”
“We’re in academic medicine in a distressing disease field that is now going through almost tumultuous development for the better,” Iyer said. “So yes, research is a responsibility.
“You can improve time to freedom from PN, you can reduce complications, you can improve survival, you can improve quality  of  life.  So  an  intestinal  rehabilitation  program should be involved in the care of these patients.”
For article references, visit www.EndoProMag.com.

### Physician Shortage
Shortages are rampant throughout healthcare staffs—so extreme that there is a projected shortage of more than three million essential low-wage health workers in the next five years, according to the U.S. Department of Health and Human Services. The problem, however, doesn’t stop with lower-wage positions: There is also a huge shortage of physicians, a problem that contributes to overall health- care burnout.
According to the Association of American Medical Colleges,1 the United States could see a shortage of 54,100-139,000 physicians by 2033. Many reasons for the shortage are being bandied about, but most experts surmise that the require- ments and journey to becoming a physician play a large part in the problem. On top of this, there is currently only a 37% acceptance rate2 for premed students seeking entrance to medical school. A main reason for this low acceptance is a high MCAT failure rate. With several causes for the physician shortage, schools, students, and medical-industry experts will have to address the issue soon if they hope to curb it.
Delays in Care
Anecdotal evidence is mounting about the long waits to see a specialist, or issues regarding family physicians not taking new patients. During the recent RSV and influen- za3 spike among children, many people reported waiting for hours—sometimes over a day—in emergency rooms to have their children seen by a staff worn thin.
Delays in care—whether prompted by the doctor shortage or other factors like affordability—are already having some devastating effects. Mortality rates in the United States are higher than those of peer countries, and the overall life expectancy4 of the U.S. population has dipped. Some may be quick to blame COVID-19 for these statistics, but studies show5 that the writing was on the wall for the U.S. long before the pandemic. Chronic health conditions such as diabetes have become more prevalent and require a lot of the healthcare industry’s already strained resources. More family physicians are needed for preventative care and specialists are needed for regular targeted follow-ups. All of this exacerbates the physician shortage.
The Road to Becoming a Doctor
On average, a medical student can expect to pay between
$157,000 and $254,0006 for medical school. Add to that any undergraduate cost, and the investment can be out of reach for many students. Even though physicians can eventually expect higher-than-average salaries, massive student-loan debt can cripple medical students financially for many years after graduation and residency.
Admissions are historically competitive, and the current ratio of applicants to admissions7 is about 16:1. Although graduation rates are relatively high for medical-school students (likely due to the overall investment), standing at roughly 81% to 84%8 overall, there is no guarantee that a student will complete their residency after they graduate.
According to studies, an average of 55%9 of doctors com- plete their required residency programs. This means just under half of would-be doctors do not go on to practice, contributing greatly to the supply-and-demand problem in the medical field. Even as the number of medical school graduates has risen, an outdated and ineffective residency-application software program was filtering out talented students, leaving many without residencies and deep in debt. According to one study, roughly 10,000 “chronically unmatched” doctors in the United States are floundering without jobs or residency appointments, being kept away due to a technical discrepancy. Students who study abroad fare even worse, with only 61%10 of those students eventually matching to a residency program in the United States.
This issue of discriminatory and technically inept practic- es in the matching process contributes significantly to the problem of physician shortages. Talented doctors are being kept from practicing, even if they are able and willing to do so. Without a residency, doctors cannot qualify for a medi- cal license. Still, residency directors continue to defend the idea of software filters that remove candidates for reasons such as the length of time between medical school gradua- tion and residency application, or a foreign-school diploma.
With thousands of applicants for a set number of residency placements, directors are counting on this software to do the legwork of reading applications and sorting out who should be disqualified—even if there is no merit to the dis- qualification.
Solving the Problem
If the physician shortage is going to be solved, those with the power to change it will have to start thinking outside the box. No single solution will put the country back on the right track, but a number of answers can certainly help lessen the blow.
The issue of supply and demand concerning residency spots should be one of the first issues addressed. The need for increased funding for hospital systems to allow them to open more residency spots has already been discussed among government and private medical groups. However, the small changes brought by the trickle of funding have not kept up with the population demands in the medical field. Increasing numbers of graduates apply for residencies each year, and there need to be more openings for them.
With the cost of medical school remaining one of the main contributors to the physician shortage, government officials have also proposed federal funding programs that would help alleviate some of the cost burden for new doctors.
Technology is increasing the availability of doctors, espe- cially telemedicine. Further investment and innovation in medical technology will increase access to doctors, thereby allowing more doctors to practice with a wider patient base. Currently, telemedicine is being used to ease burdens placed on overscheduled physicians, especially in urgent-care facil- ities and emergency rooms.
Many medical organizations are expanding the available care team for patients. Millions of patients still regularly choose to see nurse practitioners or physician assistants as their primary medical contact. This multidisciplinary approach is helping many healthy systems serve more patients.
The concept of international medical schools needs to be revisited and rethought, as well. Residency programs reg- ularly discriminate against students who received degrees from international schools, even if those schools carry the same credentials and stringent requirements as schools in the U.S. If we are going to solve the doctor shortage crisis, we need to give students broader options.
Going Forward
The physician-shortage issue will not be solved overnight. However, many government entities, healthcare facilities, and schools have made great strides in dealing with this issue head-on, helping doctors connect with patients. The more work that is done to curb the physician shortage, the better health outcomes will be. Therefore, mitigation strate- gies benefit everyone in the United States—not just hopeful doctors. The time to act is now, and with a multifaceted approach to the supply-and-demand problem, significant positive changes will arise.

### Survey: Burnout Solutions
Workforce challenges are a big part of healthcare burnout.
Indeed, “workforce challenges” ranked first on the list of hospital CEOs’ top concerns in 2022, according to the American College of Healthcare Executives’ annual survey of issues confronting hospitals. The survey results were released in February 2023.
The category of workforce challenges includes personnel shortages. This marks the second year in a row that workforce or personnel challenges has been the top-ranked issue. Before that, financial challenges ranked first in the survey for 16 consecutive years.
“Hospitals need to take both long-and short-term measures to address critical workforce issues so they can continue to provide safe, high-quality care now and in the future,” said Deborah Bowen, FACHE, CAE, president and CEO of ACHE.
“Longer-term solutions include strengthening the workforce pipeline through creative partnerships, such as those with colleges to grow the number of nurses and technicians,” Bowen added. “More immediate solutions include supporting and developing all staff, building staff resilience, organizing services to reflect the realities of the labor market and exploring alternative models of care.”
In the survey, ACHE asked respondents to rank 11 issues affecting their hospitals in order of how pressing they are and to identify specific areas of concern within each of those issues.
The American College of Healthcare Executives is an international professional society of more than 48,000 healthcare executives who lead hospitals, healthcare systems and other healthcare organizations. ACHE’s mission is to advance their members and healthcare management excellence.
Millions of people suffer daily from burnout and workrelated anxiety, especially in high-pressure careers such as healthcare. In 2019, the World Health Organization recognized burnout as an “occupational phenomenon” that deserves priority research focus. A 2023 Work
In America survey by the American Psychological Association found that more than half of the U.S. working population is experiencing stress-related symptoms of burnout, such as emotional exhaustion, lowered productivity, and a desire to quit.
Many professionals—in healthcare, for instance—feel stuck, with no way out. Typical coping tools don’t always cut it— we’ve all tried to eat more plants, do more exercise, have more social time. It seems the stress is too much, even with the aforementioned remedies.
One reason these tools aren’t always useful is because we haven’t adequately defined the problem. “Stress” is an overloaded term; it’s a good idea to dig deeper into what that actually means for each individual. That way, we can apply the right evidence-based interventions. Psychological science has some powerful tools at its disposal, but the tools need to be deployed in the right context to be helpful.
Let’s look at a specific example, drawn from my team’s clinical experience treating those in high-pressure careers: in this case, the medical field. “Ted” was in his second year as an attending orthopedic surgeon in a major hospital system. He had made it through competitive and selective programs in college, medical school, residency and a fellowship. He chose orthopedics because he loved the feeling of “fixing problems,” such as by helping people get healthy and back on their feet.
But suddenly, almost overnight, Ted felt that his interest in his work had disappeared. He was exhausted, deeply unmotivated, and apathetic in a way he had never been before. Reading up on the science of stress and burnout, he thought maybe he needed to exercise more, get out of the house, or catch up from years of sleep deprivation. Shifting into the same problem-solving mode that had gotten him this far in life, he carved out time for the gym, tried to go to bed a half hour earlier each night, and cut out processed foods (a real challenge when most of his meals came from the hospital cafeteria).
It didn’t help. At first glance, Ted seemed like he was suffering from classic burnout symptoms related to work stress. In our sessions, though, it emerged that the driving force behind this mindset shift was more fundamental than that.
Ted had never wondered why “fixing” his patients’ problems was so motivating for him. But when he began to dig into his personal values in our sessions (using the techniques of Acceptance and Commitment Therapy (ACT)), he realized that his underlying motivation was to demonstrate his own competence—to others, but also to himself. Ted was struggling with significant impostor syndrome, which he self-medicated by choosing a field where he felt he could demonstrate concrete and direct impact. However, the field never truly satisfied his intellectual curiosity or emotional needs.
In fact, Ted had always been fascinated by oncology, but had built it up as being somehow above his skills and capabilities—an inaccessible specialty filled with MD/PhDs and biochem geniuses. He worked on his cognitive distortions through Cognitive Behavioral Therapy (CBT), and was able to address these automatic negative thoughts about his abilities. This therapy helped him gain an accurate reflection of himself that allowed him to pivot into a research field that incorporated both oncology and orthopedics. With this change in place, he found he was much more energized. His mood lifted and he was excited about going to work again.
Ted was able to use specific tools from psychological science to improve his situation, but only once he dug in to figure out why he was struggling. Gaining self-knowledge about your values, needs, and motivations lets you deploy a targeted combination of evidence-based approaches (such as CBT, ACT, and others), rather than relying on a one-dimensional diagnosis and treatment pattern.
This is a challenge we see again and again in our field: People want to know what “the science” says about fixing their problems, but it’s far more complex and individualized than that. The only commonality is that self-discovery is the first step; before you can know which direction to go, you need to know where you are.

### Merci du Complément
Yarg.
I hate “alternative medicine.” Alternative medicine suggests that the patient has turned their backs on conventional/ Western/boring medicine and has headed out on a fantastical pathway of crystals, oils and unresearched herbals. As a Western medicine practitioner, I respect that my medical care is backed with peer-reviewed articles. I also recognize the validity of Eastern medicine, with its centuries of empiric evidence, and more recently, published data as well. And I heartily embrace complementary medicine—more on that in a bit.
My dislike—nay, hatred—of alternative medicine comes via the deaths of two friends. Early in my gastroenterology career, my roommate, Stephanie, had found a breast lump. After a non-diagnostic needle biopsy of the mass, she elected to “go alternative,” although her medical team strongly encouraged a second biopsy via ultrasound guidance. She drank hot potions of stewed balls of something noxious (that I swear, based on the smell, was manure) and juiced alfalfa and carrots—half our shared refrigerator was full of bags of carrots and sod. I bit my tongue firmly and was ready to offer medical insight and advice when asked—yet she didn’t ask. The end of her story was death by metastatic breast cancer, despite last-ditch efforts of surgery, radiation and chemotherapy.
Another vibrant friend, Sandy, died of “dunno what.” She began to waste away, weakness progressing and eventually rendering her unable to walk and confined to her second-floor bedroom. She continued to see her alternative medicine practitioner, who treated her with oils and crystals, but without any Western medicine testing or evaluation. Was it autoimmune? Cancer? My differential diagnosis without any exam or testing was vast. I visited Sandy with a mutual friend mid-course, and the changes wrought by her illness were shocking. She also died, but I continue my belief that the culprit may have been manageable or curable with the application of science.
However, I have no beef with—and even joyously embrace— complementary medicine. The American Heritage Dictionary defines complementary medicine as “a method of healthcare that combines the therapies and philosophies of conventional medicine with those of alternative medicines, such as acupuncture, herbal medicine, and biofeedback.”
In fact, finding complementary medicine practices that have medical science to support them gives me a head rush. They are a positive action that you as patient might adopt, with little chance of a downside, side effect or complication—and you get to assume some measure of ownership of your health. There are a slew of data-supported complementary practices; here are some of my favorites that you might incorporate into your life as a healthcare professional, or into your patients’ or family’s lives.
Probiotics and Cranberries to Reduce Chronic UTI
Use of probiotics, specifically lactobacillus rhamnosis and lactobacillus reuteri, have been demonstrated in the spinal-cord injury population requiring intermittent catheterization, and in the mainly female recurrent/chronic UTI population, to reduce the bacterial counts (mainly gastrointestinal E. coli), reduce adherence of pathogenic bacteria to the urinary mucosa, reduce recurrent infections, and reduce antibiotic resistance of the pathogenic bacteria.
The data isn’t perfect,1,2,3 but I was moved to go online and put Mom on a daily probiotic of lactobacillus rhamnosus GR-1 and lactobacillus reuteri RC-14 strains for her chronic multidrug-resistant UTI. Oh, and her daily fresh cranberry orange relish that Mom swears by helps too, just as she said. The recipe follows.
Nancy Raymond’s Cranberry Orange Relish Recipe
 	3 cups fresh or frozen cranberries
 	2 navel oranges, washed, unpeeled and quartered
 	1 cup sugar, or less to taste (I prefer about 1/3 cup—it’s easy to add more later)
 	1/2 cup pecans, finely chopped
Add the oranges to a food processor and whiz until they are finely ground to pulp. Add the cranberries and sugar, and pulse until just coarsely ground. Remove to a storage bowl and stir in the pecans. Cover and refrigerate.
Dietary Strawberries for Osteoarthritis of the Knees in Overweight Postmenopausal Women
Yikes. The title says it all.
However, in Schell’s elegant, double-blind crossover study, participants drank either faux strawberry milkshakes or those made with freeze-dried strawberries (equivalent to about a pound of berries daily) for 12 weeks, with a two-week washout period. The results showed significant decrease of serum biomarkers of inflammation and cartilage degradation [interleukin (IL)-6, IL-1β, and matrix metalloproteinase (MMP)-3] after daily strawberry ingestion. Eating strawberries didn’t just improve labs; the berries also significantly reduced constant, intermittent and total pain and improved a quality-of-life assessment score (HAQ-DI).
Some studies suggest that strawberries reduce the proinflammatory and glucose surge effect when acutely taken with a non-nutritious meal and can downgrade the histologic grade of dysplastic esophageal lesions, which your Barrett’s patients might like to hear.4,5
Yup, I’m enjoying my daily berries, be they fresh, frozen, or freeze-dried from Trader Joe’s. Nope, no untoward side effects so far. (Hint: they’re strawberries.)
Boswellia (Frankincense) for Knee and Hip Pain as an Alternate NSAID
Here’s a particular favorite: Boswellia serrata, an extract from the frankincense plant, is an anti-inflammatory that works via a different pathway that the standard NSAIAs. It’s slow in onset (don’t expect the rapid relief you can achieve with a dose of ibuprofen); it seems to reach efficacy in about five to seven days, in my personal experience. As it follows a different pathway, it doesn’t cause the gastrointestinal irritation and ulcers common with other anti-inflammatories.
Studies show efficacy pain relief in knee and hip osteoarthritis,6,7,8 and it’s been trialed for pancreatitis and for treatment-induced swelling by irradiation of brain tumors, among other inflammatory processes. In the osteoarthritis studies, they reported a reduction in C-reactive protein, and in radiographs, improved knee joint gap and reduced osteophytes.
Researchers believe it may have efficacy in a plethora of chronic diseases, which raises a major red flag for me: “chronic diseases like arthritis, diabetes, asthma, cancer, inflammatory bowel disease, Parkinson’s disease, [and] Alzheimer’s.” This gets a little Middle Earth to me, as in “One Ring to rule them all, One Ring to find them, One Ring to bring them all, and in the darkness bind them” (JRR Tolkien). A worrisome overpromise, in my opinion.
When I suggest the use for arthritis pain and stiffness, target dosage is 600 milligrams daily, and I suggest initial trial use for a month. It is difficult to determine the absence of discomfort, so at the end of month one, I recommend stopping the Boswellia. In most, the missing discomfort is uncovered after several days of abstinence. Useful information for your arthritis-ridden ulcer patients, no?
Turmeric for Ulcerative Colitis Maintenance of Remission
I’m passionate about this complementary move, not only for my erstwhile patients, but also because a family member was recently diagnosed with ulcerative colitis. I frequently suggested to my patients that turmeric had a studied beneficial effect on their colitis course. In this recent meta-analysis of seven turmeric studies, combining use of curcumin with mesalamine in mild-to-moderate UC yields both a superior clinical and endoscopic response.9 Yes, it actually works “for realz.”
Their analysis was:
 	Odds ratio (OR) for clinical remission with curcumin was 2.9
 	OR for a clinical response with curcumin was 6
 	OR for an endoscopic response and/or remission with curcumin was 2.3
Yes, that’s makes success about two to three times more likely for your patients, no matter how you’ve defined success.
Type 2 Diabetes and the Vegan Diet
Although the vegan diet is rich in high-fiber carbohydrates, this whole-food, plant-based diet is now widely understood to prevent, treat and even reverse Type 2 diabetes.10 And the complications, cardiac and renal disease and diabetic neuropathy all also improve with a vegan diet.
Why wouldn’t you offer this information and the support to make this choice for your diabetics?
There are uncountable others—it’s worth going to Dr. Google to see what’s the buzz, and then into PubMed and entering your disease du jour and seeing what complementary agents have been studied. If you feel moved to add some complementary medicine to your practice or your life, peruse the medical literature yourself and weigh the risks and benefits. For me, the risks (usually a modest expense) versus the benefits (somewhat soft data, but data nonetheless) make complementary medicine worth trying.
After all, what’s the alternative?
For article references, visit www.EndoProMag.com.

### Personal Protective Equipment
The Occupational Health and Safety Administration’s regulation on occupational exposure to bloodborne pathogens requires employers to identify employees and tasks that might put them at risk for exposure to blood and/or other body fluids, and to take appropriate measures to protect them from exposure. The regulation includes requirements for appropriate personal protective equipment (PPE). The type of PPE might vary, according to the tasks to be performed.
According to OSHA, however, the PPE selected must “not permit blood or other potentially infectious materials to pass through or reach the employee’s work clothes, street clothes, undergarments, skin, eyes, mouth or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used” (29 CFR 1910.1030).
The use of PPE is not optional. It is the employer’s responsibility to provide appropriate PPE, ensure that it is used, and document and investigate any failure to comply. All employees should be trained in the appropriate protective attire to be worn for the tasks they perform and also in the potential health and disciplinary consequences if they fail to do so. This training should be documented and routinely verified as part of departmental competencies.
Recommended PPE
The Emergency Care Research Institute’s 2022 List of Healthcare’s Top Ten Hazards include two that are specific to endoscopy: when poor duodenoscope processing ergonomics and workflow in endoscopy puts healthcare workers at risk; and when disposable gowns with insufficient barrier protection puts wearers at risk. Because of the potential for soaking clothing, splashing and the aerosolization of fluids and contaminants, and the consequent need to protect employees from exposure to both microorganisms and chemicals, appropriate PPE in the scope-cleaning area includes the following items per ANSI/AAMI ST91:
 	General-purpose utility gloves and a liquid-resistant covering with sleeves (for example, a backless gown or surgical gown). Processing personnel should use a glove style that prevents contact with contaminated water. Gloves that are too short, do not fit tightly at the wrist or lack cuffs might allow water to enter when the arms move up and Many companies offer longer length (18-inch) decontamination gloves. Exam gloves should not be used for decontamination. General-purpose utility gloves fitted at the wrist or above should be used. Note: The gloves should be designated as “decontamination gloves,” which are thicker and provide additional support from punctures.
 	A long-sleeved, impervious (fluid-proof) or fluid-resistant gown or jumpsuit. When there is a possibility that attire can become soaked with blood or other potentially infectious material, as when items are being washed by hand, a Level 4 gown (as defined by ANSI/AAMI PB70) should be used.
 	A fluid-resistant face mask and eye protection. PPE used to protect the eyes from splash could include goggles, full-length face shields, or other devices that prevent exposure to splash from all angles. Note: Masks with visors do not meet these criteria because a splash could occur from the top of the visor.
 	Fluid-protective shoe covers with slip-proof bottoms. Shoe covers are recommended when there is the potential for shoes to become contaminated with blood or other body Shoe covers should be removed before leaving the scope-cleaning area in order to contain microorganisms and other contaminants (OSHA 29 CFR 1910.1030).
 	Hearing protection. If noise levels exceed OSHA-permissible levels for the OSHA-designated time duration, hearing protection should be available (29 CFR 1910.95 g).
Reusable gloves, glove liners, aprons and eye-protection devices should be decontaminated according to the manufacturer’s written instructions for use (IFU) at least daily and between employees. If the integrity of an item has been compromised, it should be discarded. Personnel should remove torn gloves and thoroughly wash their hands before donning new gloves. They should remove PPE worn during processing and wash their hands. Before handling disinfected endoscopes, personnel should don clean PPE (ANSI/AAMI ST91).
Before leaving the cleaning area, employees should remove all protective attire, being careful not to contaminate the clothing beneath or their skin. Then they should perform appropriate hand hygiene. Designated areas with the necessary containers should be provided for donning and removing protective attire (ANSI/AAMI ST91). PPE should be located at the entrance to the decontamination area so staff and visitors can don it without walking through the area. In addition, PPE should be protected from contamination by keeping it in closed carts or bins.
A study by Kang, et al., discovered that healthcare personnel contaminated themselves in almost 80 percent of PPE simulations—an astonishing statistic. Therefore, endoscopy departments should establish competencies for donning and doffing PPE. Training and annual competency assessments should be documented in each employee’s record.
Donning (Applying) PPE
The CDC offers a poster with instructions for donning and doffing PPE. It does not include shoe covers, as the poster was developed during the Ebola outbreak; however, shoe covers were added in this listing below. When applying PPE, the recommended sequence is based largely on CDC guidelines.
 	Shoe covers should be donned Then wash your hands.
 	Gown should be donned
 	To don a gown, first select the appropriate type for the task and the right size.
 	The gown should open in the back. Secure the gown at the neck and waist.
 	Mask should be put on next; ensure it is properly adjusted to fit.
 	Some masks are fastened with ties, and others with else If the mask has ties, place the mask over your mouth, nose and chin. Fit the flexible nosepiece to the form of your nose bridge. Tie the upper set of ties at the back of your head and the lower set at the base of your neck.
 	Goggles or face shield should be donned next.
 	Position either the goggles or the face shield over your face and/or eyes and secure it to your head using the attached earpieces or headband. Adjust it to fit comfortably. Goggles should feel snug but not tight. Note: Safety eyeglasses are not a substitute for goggles or a face shield.
 	Gloves are donned
 	Insert each hand into the appropriate glove and adjust as needed for comfort and If you are wearing an isolation gown, tuck the gown cuffs securely under each glove to provide continuous barrier protection for your skin.
Doffing (Removing) PPE
To remove PPE safely, it is first necessary to identify which sites are considered “clean” and which are considered “contaminated.” In general, the shoe covers, the outside front and sleeves of the gown, and the outside front of the mask and goggles or face shield are considered contaminated, regardless of whether there is visible soil. The outside of the gloves is also contaminated. The areas that are considered clean are the parts that will be touched when removing PPE: the inside of the gloves; the inside and back of the gown, including the ties; and the ties, elastic or earpieces of the mask and goggles or face shield. The sequence for removing PPE is intended to limit opportunities for self-contamination.
 	Shoe covers are considered to be the most contaminated pieces of PPE and are therefore removed first.
 	Gloves are removed With a gloved hand, grasp the opposite glove and peel the glove off. Hold the removed glove in the gloved hand. Carefully slide the fingers of the ungloved hand under the top of the remaining glove (at the wrist) and peel that glove off over the first glove removed. Discard the gloves.
 	Goggles or face shield should be removed Because the outside of the goggles or face shield is considered contaminated, remove goggles or face shield by grasping the earpieces or headband. Using ungloved hands, grasp the “clean” earpieces or headband and lift them away from your face. If the goggles or face shield are reusable, place them in a designated receptacle for subsequent reprocessing. Otherwise, discard them in the designated waste receptacle.
 	Gown should be removed next. Unfasten the gown ties with the ungloved Slip your hands underneath the gown at the neck and shoulder and peel away the gown from your shoulders. Slip the fingers of one hand under the cuff of the opposite arm. Pull your hand into the sleeve, grasping the gown from the inside. Reach across and push the sleeve off the opposite arm. Fold the gown toward the inside and fold or roll it into a bundle. (Only the “clean” part of the gown should be visible.) Place the gown into a waste or linen container, as appropriate.
 	The mask is next. Do not touch the front of the mask to remove it. Untie the bottom tie and then, using the upper tie, lift off the mask. Discard it in a waste container.
 	Although not considered part of the PPE, the head cover should be removed last before leaving the decontamination area. Lift the head covering off the head by grasping it in the center and lifting it Discard in a waste container.
 	Thoroughly wash hands.
Personnel should remove PPE and head coverings when they leave the scope-cleaning room and then immediately wash their hands. A poster depicting the process of donning and doffing PPE can be obtained on the CDC website (www.cdc.gov) and placed in a prominent space in the endoscopy department. The type of PPE should be based on the potential for exposure. PPE samples should be obtained before purchasing or changing to another type of PPE to ensure it meets the requirements. However, the correct procedures for donning and doffing PPE are just as important and need to be addressed for staff safety.
For article references, visit www.EndoProMag.com.
 

### Simply One of the Best
At Athens-Clarke County Endoscopy Center in Athens, Georgia, the focus is on teamwork and excellent patient care. Lynn Tobin, endoscopy manager, said the team consists of a receptionist, four endoscopy techs, three endoscopy RNs, one endoscopy LPN, an endoscopy manager, four CRNAs, and four gastroenterologists.
“Our center performs colonoscopies, esophagogastroduodenoscopy (EGD), esophageal dilations, and Bravo pH Test. We have four pre-op bays, four post-op bays, two procedure rooms, and one scope room,” Tobin said.
Gastroenterologists include Doctors Kelly Grow, Lori Lucas, Erik Person and Bradley Shepherd, all of whom are board-certified. A member of United Digestive, Athens-Clarke was named one of the highest performing ambulatory surgery centers (ASCs) in the country by U.S. News & World Report. Factors used to evaluate ASCs included whether patients avoided complications like ER visits and unplanned hospitalizations.
Athens-Clarke County Endoscopy
“Everyone works together as a team to ensure that we are providing the best care to our patients,” Tobin said. “We share the same goals, and everyone is required to maintain competency and practice according to the standards of care. Our staff is very versatile, as each staff member is cross-trained in multiple areas of the center.”
They’re a team personally as well as professionally. Tobin described the group as “very close,” detailing how team members check in on each other and celebrate personal events, holidays and milestones. “On one occasion, one of our endoscopy nurses used his personal day off to support the staff by smoking barbecue and bringing it for the team to enjoy a nice lunch,” said Betsy Hefner, endoscopy LPN.
As with all teams, Tobin admitted it hasn’t always been smooth sailing. “We have had some staffing challenges in the past, which brought us all closer as a team because we had to support each other to ensure that we continued to provide excellent care to our patients.” Tobin said communication is key. Team members are welcome to share ideas for improvement, ensuring that the team is able to provide patients the best possible care.

### Healthcare Burnout
I've always sympathized with health workers, and then the pandemic struck, and my sympathy increased tenfold. You were already individuals from whom too much was expected, and then we as a society tripled up in expecting too much of you.
Whenever I read about medical practitioners suffering from healthcare burnout, I think, "Of course. Why wouldn't they?"
The amount of stuff that would burn you out is simply too huge. Just a scattering: Long work hours
Rude patients
Insurance companies
Bureaucracy
Staff shortages
Working on your feet all day
Having to continually renew your education
Rushed appointments
Cyberattacks
Pressure
Problematic health systems
Occupational hazards
Fatigue
I do not know how each of you can take care of patients and/or equipment (technicians) for a whole day and then get home and take care of someone else. Even if you do not give care outside of work, it's still difficult to work and then take care of yourself, your house, and perhaps some animals.
I just couldn't do what you do—too many reasons, one being how high-stakes your career is. For example, I might mess up in my line of work. I might get people the wrong information, and there might be repercussions, but nobody will die. Suppose a healthcare worker has a bad day and messes up: That error might kill someone.
My mother was a nurse, my husband's parents are nurses, a great many others on my husband's side work in healthcare, and I have a few friends who are doctors or physician's assistants. Through them, and you, I observe the many conditions that could cause healthcare workers to become burned out.
Because healthcare burnout is on the rise, we've put together a cover package on the subject in this issue of our magazine. If you feel like you're drowning, I hope the articles will make you feel less isolated. For better or for worse, as far as burnout goes, you're among friends. And if none of the above describes you and you're still wide-eyed and bushy-tailed, three cheers to that!
To locate the burnout article, go to p. 18, and may you discover the rest you require, burned out or wide-eyed.

### Healthmark Offers New Humipak for Robotic Instruments
Healthmark, A Getinge Company has announced they are now offering the Humipak for Robotic Instruments to its SST Instrument Retrieval product line. 
Manufactured from polyester-polypropylene films with a highly hydrophilic, blue viscose inner liner, the Humipak for Robotic Instruments consists of a layer of highly absorbent material sandwiched between two layers of waterproof film and are offered in the following sizes: 8.3 x 32 In. and 16.5 x 32 In. Designed as single use, the 8.3 x 32 In. Humipak is designed for a single robotic instrument, whereas the 16.5 x 32 In. Humipak is for four robotic instruments. Simply, place the instruments inside the Humipak, add the specified amount of water to the absorbent layer, and seal with the peel away adhesive strip. This creates a watertight, moist atmosphere that will prevent organics from drying over an extended period. The Humipak for Robotic Instruments are available for purchase in a pack of twenty-five and a case of one hundred.
 Visit www.hmark.com for more information. 

### Pure Processing Launches Brush for 3-Stage Endoscope Cleaning
CAROL STREAM, Illinois—Pure Processing, a leader in ergonomic solutions for fast, safe, and effective medical device pre-cleaning, announced recently that it has added the SuperDART® ONE PASS™ Endoscope Cleaning Brush to its line of high-quality products and accessories.
The SuperDART® disposable channel cleaning brush has been tested and shown to exceed AAMI TIR30 requirements for cleaning efficacy.
Pure Processing founder and CEO Dan Gusanders explained, “As endoscope-related adverse events continue to rise, we knew there was an opportunity to introduce a better, more effective technology. SuperDART® was the only tested and validated solution that achieved repeatable cleaning conditions.”
The SuperDART® brush only needs one pass through an endoscope channel to deliver validated cleaning results. The SuperDART® features a three-stage construction with integrated squeegee technology that saves time and reduces operator fatigue while providing patients with the highest standard of hygiene.
The SuperDART® ONE PASS™ Endoscope Cleaning Brush is ideal for channels ranging in size from 2.0 mm to 4.2 mm and is compatible with most endoscope channels. It works in stages beginning with a leading brush which dislodges debris from the channel walls. Then, in the second stage, the multi-disk squeegee sweeps debris away and swipes the channel walls clean. In the final stage, a bristled tail brush meticulously tackles remaining debris and biofilm, ensuring a pristine finish before the final flush with a detergent solution.
According to Gusanders, “While other brushes have demonstrated effectiveness in undamaged, new channels, SuperDART® has demonstrated to be effective in all channel conditions. It’s a better solution for real-world lumen conditions.”
For more information, including FAQs, test results, and comparison charts, see the Pure Processing website here.
 

### Chronic Gastrointestinal Disorders Treatment Options and Approaches
Chronic gastrointestinal (GI) disorders are long-term conditions that affect the digestive system, causing discomfort, pain, and other symptoms that can significantly impact daily life. These disorders include conditions such as Crohn's disease, ulcerative colitis, irritable bowel syndrome (IBS), celiac disease, and chronic pancreatitis. Effective chronic gastrointestinal disorders treatment requires a comprehensive approach that includes medication, lifestyle changes, dietary adjustments, and sometimes surgery. We will explore options for managing gastrointestinal disease treatment to help individuals improve their quality of life.
Understanding Chronic Gastrointestinal Disorders
Chronic gastrointestinal disorders often require long-term management due to their persistent nature. Some common chronic GI disorders include:
 	Crohn's Disease: An inflammatory bowel disease (IBD) that can affect any part of the gastrointestinal tract, causing inflammation, ulcers, and other complications.
 	Ulcerative Colitis: Another form of IBD that specifically affects the colon and rectum, leading to inflammation and ulcers in the lining of the large intestine.
 	Irritable Bowel Syndrome (IBS): A functional disorder characterized by abdominal pain, bloating, and changes in bowel habits (diarrhea, constipation, or both).
 	Celiac Disease: An autoimmune disorder where ingestion of gluten leads to damage in the small intestine.
 	Chronic Pancreatitis: Inflammation of the pancreas that does not heal or improve, leading to permanent damage and affecting the digestive process.
Medication for Chronic Gastrointestinal Disorders
Medications play a critical role in managing chronic GI disorders. The choice of medication depends on the specific disorder, its severity, and the individual patient's response to treatment.
Anti-inflammatory Drugs
 	Aminosalicylates (5-ASAs): These drugs, such as mesalamine, sulfasalazine, and olsalazine, help reduce inflammation in the lining of the intestines. They are commonly used as part of gastrointestinal disease treatment to manage mild to moderate Crohn's disease and ulcerative colitis..
 	Corticosteroids: These powerful anti-inflammatory drugs, including prednisone and budesonide, are used for short-term relief during flare-ups of IBD. They play a crucial role in gastrointestinal disease treatment, although long-term use is limited due to potential side effects..
Immunosuppressants
 	Azathioprine and Mercaptopurine: These medications suppress the immune system's response, reducing inflammation and helping maintain remission in IBD patients.
 	Methotrexate: An immunosuppressant that can be used for patients with Crohn's disease who do not respond to other treatments.
 	Biologic Therapies: Biologics, such as infliximab, adalimumab, and ustekinumab, target specific components of the immune system to reduce inflammation. They are used for moderate to severe cases of IBD.
Antibiotics
 	Metronidazole and Ciprofloxacin: These antibiotics are sometimes prescribed for Crohn's disease to treat or prevent infections in the intestines.
Antidiarrheals and Laxatives
 	Loperamide: An over-the-counter medication that can help control diarrhea in IBS and other chronic GI disorders.
 	Polyethylene Glycol (PEG): A laxative used to treat constipation associated with IBS.
Pain Management
 	Antispasmodics: Medications such as hyoscyamine and dicyclomine help reduce abdominal pain and cramping in IBS.
 	Tricyclic Antidepressants: Low doses of these medications, such as amitriptyline, can help manage pain and improve symptoms in IBS.
Dietary Adjustments
Diet plays a crucial role in managing chronic gastrointestinal disorders treatment. Making appropriate dietary changes can help alleviate symptoms, prevent flare-ups, and improve overall digestive health.
Low-FODMAP Diet
The low-FODMAP diet is commonly recommended for individuals with IBS. FODMAPs are short-chain carbohydrates that can be poorly absorbed in the small intestine, leading to gas, bloating, and diarrhea. The diet involves eliminating high-FODMAP foods and gradually reintroducing them to identify triggers.
Gluten-Free Diet
For individuals with celiac disease, adhering to a strict gluten-free diet is essential. This involves avoiding all foods containing wheat, barley, rye, and their derivatives. Even small amounts of gluten can trigger symptoms and cause damage to the small intestine.
Specific Carbohydrate Diet (SCD)
The SCD is a dietary plan used by some people with Crohn's disease and ulcerative colitis. It eliminates complex carbohydrates and focuses on simple, easily digestible foods to reduce inflammation and improve gut health.
Anti-inflammatory Diet
An anti-inflammatory diet emphasizes foods that reduce inflammation and promote gut health. This includes:
 	Omega-3 Fatty Acids: Found in fatty fish (salmon, mackerel), flaxseeds, and walnuts.
 	Fruits and Vegetables: Rich in antioxidants and fiber.
 	Whole Grains: Such as brown rice, quinoa, and oats.
 	Probiotics and Fermented Foods: Yogurt, kefir, sauerkraut, and kimchi can help maintain a healthy gut microbiome.
Lifestyle Changes
In addition to medication and dietary adjustments, lifestyle changes can significantly impact the management of chronic gastrointestinal disorders.
Stress Management
Stress can exacerbate symptoms of chronic GI disorders, particularly IBS. Incorporating stress-reducing techniques into daily life can help manage symptoms:
 	Exercise: Regular physical activity can reduce stress and improve overall well-being.
 	Mindfulness and Meditation: Techniques such as mindfulness meditation, yoga, and deep breathing exercises can help reduce stress and improve digestive health.
 	Cognitive Behavioral Therapy (CBT): CBT can help individuals develop coping strategies for managing stress and anxiety related to chronic GI disorders.
Regular Physical Activity
Engaging in regular exercise can help improve digestion, reduce inflammation, and promote overall health. Activities such as walking, swimming, cycling, and yoga is particularly beneficial.
Adequate Hydration
Staying well-hydrated is essential for digestive health. Drinking plenty of water throughout the day helps maintain bowel regularity and prevent constipation.
Surgical Interventions
In some cases, surgery may be necessary to manage chronic GI disorders, particularly when other treatments have not been effective.
Resection Surgery
 	For Crohn's Disease: Surgical removal of the affected portion of the intestines (resection) may be required to manage severe symptoms or complications.
 	For Ulcerative Colitis: In severe cases, removal of the colon and rectum (proctocolectomy) may be necessary. This can be followed by the creation of an ileostomy or an ileal pouch-anal anastomosis (IPAA).
Strictureplasty
This surgical procedure is used to widen narrowed sections of the intestines caused by chronic inflammation in Crohn's disease, helping to alleviate symptoms and improve bowel function.
Colectomy
In cases of severe chronic ulcerative colitis, a colectomy (removal of the colon) may be performed. This can be followed by the creation of an ileostomy or the construction of an internal pouch (J-pouch) to collect waste.
Alternative and Complementary Therapies
Some individuals with chronic gastrointestinal disorders seek alternative or complementary therapies to manage their symptoms. While these therapies should not replace conventional treatments, they can be used alongside them for additional relief.
Acupuncture
Acupuncture involves inserting thin needles into specific points on the body to promote healing and alleviate pain. Some studies suggest that acupuncture may help reduce symptoms of IBS and other chronic GI disorders. As a complementary approach to gastrointestinal disease treatment, acupuncture may assist in managing digestive discomfort and improving overall gut health.
Herbal Remedies
Certain herbal remedies, such as peppermint oil, ginger, and turmeric, have been used for chronic gastrointestinal disorders treatment. However, it's essential to consult with a healthcare provider before using any herbal supplements, as they can interact with medications and have side effects.
Probiotics
Probiotics are beneficial bacteria that can help maintain a healthy balance of gut microbiota. They may help manage symptoms of IBS, IBD, and other chronic GI disorders. Probiotic supplements and fermented foods can be incorporated into the diet to support digestive health.
Conclusion
Managing chronic gastrointestinal disorders requires a comprehensive and individualized approach. Medications, dietary adjustments, lifestyle changes, and sometimes surgery are essential components of effective treatment. By working closely with healthcare providers and adopting a holistic approach to management, individuals with chronic GI disorders can achieve better symptom control and improve their quality of life. If you have a chronic GI disorder, consult with your healthcare provider to develop a personalized gastrointestinal disorders treatment plan that addresses your specific needs and goals.

### Understanding Digestive Disorders: Symptoms and Insights
Digestive disorders encompass a wide range of conditions that affect the gastrointestinal (GI) tract, which includes the esophagus, stomach, intestines, liver, pancreas, and gallbladder. Recognizing the symptoms of these disorders is crucial for early diagnosis and effective treatment. This article delves into common digestive disorders and their associated symptoms, providing insights to help you understand and manage these conditions better.
Common Digestive Disorders
 	Gastroesophageal Reflux Disease (GERD)
 	Irritable Bowel Syndrome (IBS)
 	Celiac Disease
 	Crohn's Disease
 	Ulcerative Colitis
 	Gallstones
 	Lactose Intolerance
Gastroesophageal Reflux Disease (GERD)
GERD is a chronic condition where stomach acid frequently flows back into the esophagus, leading to irritation.
Digestive Disorders Symptoms:
 	Heartburn: A burning sensation in the chest, often after eating, which might be worse at night.
 	Regurgitation: Acidic or bitter-tasting fluid backs up into the throat or mouth.
 	Dysphagia: Difficulty swallowing.
 	Chest pain: Sometimes mistaken for heart-related issues.
 	Chronic cough: Often worse at night or after meals.
 	Hoarseness: Especially in the morning.
Irritable Bowel Syndrome (IBS)
IBS is a common disorder affecting the large intestine, characterized by abdominal pain and altered bowel habits.
Digestive Disorders Symptoms:
 	Abdominal pain and cramping: Often relieved by passing stool.
 	Bloating and gas: Frequent and uncomfortable.
 	Diarrhea or constipation: Sometimes alternating between the two.
 	Mucus in stool: A noticeable sign of IBS.
Celiac Disease
Celiac disease is an autoimmune disorder where ingesting gluten leads to damage in the small intestine.
Digestive Disorders Symptoms:
 	Diarrhea: Frequent, watery stools.
 	Bloating and gas: Severe abdominal discomfort.
 	Fatigue: Chronic tiredness due to malabsorption of nutrients.
 	Weight loss: Unexplained and unintentional.
 	Anemia: Often due to iron deficiency.
 	Dermatitis herpetiformis: A skin rash commonly associated with celiac disease.
Crohn's Disease
Crohn's disease is a type of inflammatory bowel disease (IBD) that can affect any part of the GI tract, from the mouth to the anus.
Digestive Disorders Symptoms:
 	Abdominal pain and cramping: Severe and persistent.
 	Diarrhea: Often severe and chronic.
 	Fatigue: Constant tiredness and lack of energy.
 	Weight loss: Unintended and significant.
 	Fever: Sometimes present during flare-ups.
 	Mouth sores: Ulcers in the mouth.
Ulcerative Colitis
Ulcerative colitis is another form of IBD, specifically affecting the colon and rectum.
Digestive Disorders Symptoms:
 	Diarrhea with blood or pus: A hallmark symptom.
 	Abdominal pain and cramping: Especially before passing stool.
 	Urgency to defecate: Frequent and sudden urges.
 	Weight loss: Often due to loss of appetite and nutrient absorption issues.
 	Fatigue: Persistent tiredness.
 	Fever: Sometimes during active disease periods.
Gallstones
Gallstones are hardened deposits of digestive fluid that can form in the gallbladder.
Digestive Disorders Symptoms:
 	Sudden and intense pain: Usually in the upper right abdomen or center.
 	Pain between shoulder blades: Often radiating from the abdominal area.
 	Nausea or vomiting: Commonly accompanies pain.
 	Indigestion: Chronic and severe after meals.
Lactose Intolerance
Lactose intolerance is the inability to digest lactose, a sugar found in milk and dairy products.
Digestive Disorders Symptoms:
 	Diarrhea: Shortly after consuming dairy.
 	Bloating and gas: Severe abdominal discomfort.
 	Abdominal cramps: Often intense and painful.
 	Nausea: Sometimes accompanied by vomiting.
Recognizing Digestive Disorders Symptoms and Seeking Help
Recognizing the symptoms of digestive disorders is the first step towards effective management. Here are some tips:
 	Keep a Symptom Diary: Record what you eat, your symptoms, and their severity.
 	Consult a Healthcare Professional: Early diagnosis can prevent complications.
 	Consider a Specialist: A gastroenterologist specializes in digestive disorders.
 	Lifestyle Modifications: Diet changes, stress management, and exercise can alleviate symptoms.
Managing Digestive Disorders Symptoms
Management of digestive disorders often involves a combination of medication, dietary changes, and lifestyle adjustments.
Medications:
 	Antacids and H2 blockers: For GERD and heartburn.
 	Antispasmodics: For IBS-related cramping.
 	Anti-inflammatory drugs: For IBD conditions like Crohn's disease and ulcerative colitis.
 	Enzyme supplements: For lactose intolerance.
Dietary Changes:
 	Elimination Diet: Identify and avoid trigger foods.
 	Gluten-Free Diet: Essential for managing celiac disease.
 	Low-FODMAP Diet: Beneficial for IBS.
Lifestyle Adjustments:
 	Regular Exercise: Improves digestion and reduces stress.
 	Stress Management: Techniques like yoga and meditation.
 	Adequate Hydration: Important for all digestive health.
Conclusion
Digestive disorders can significantly impact the quality of life, but understanding their symptoms and seeking appropriate care can lead to effective management and relief. If you experience persistent or severe digestive disorders symptoms, consult a healthcare professional for a thorough evaluation and personalized treatment plan. Taking proactive steps can help you manage your digestive health and improve your overall well-being.

### Polypectomy During Insertion
Polypectomy is an obvious reason for colonoscopy: finding the little devils that can morph into something cancerous and cutting them out before they begin their deadly invasion. Standard operating procedure for many endoscopy pros is to mark polyps on the way to the cecum and then remove them on the way out. Traditionally, that’s how it’s been done.
There’s just one problem: Polyps can hide.
Finding a previously noted polyp during scope removal is often easier said than done. Precious minutes can be wasted doing a search, or the polyp may not be found at all. Reasons include small polyp size and cold-snare removal, according to Komeda, et al., who wrote, “It was difficult to retrieve small, sessile, and proximal colon polyps.”
Teramoto, et al., performed a multicenter randomized controlled trial (also known as the PRESECT study). They discovered that performing polypectomy during insertion “significantly shortens the total procedure time and eliminates all missed polyps without experiencing any disadvantages.”
In another randomized controlled trial, Wildi, et al., evaluated polypectomy on insertion and withdrawal for 301 patients. While all polyps detected on insertion and withdrawal were easily removed at the time they were found, 7.3% of polyps slated to be removed on withdrawal only were subsequently not found. The authors wrote, “Removal of polyps ≤ 10 mm during withdrawal only is associated with a considerable polyp miss rate. We therefore recommend that these polyps are removed during both insertion and withdrawal.”
Conversely, a 2021 systematic review and meta-analysis concluded that there were “no obvious advantages” to polypectomy during both insertion and withdrawal phases. And Moons, et al., stated that “maneuvers can be applied during insertion and withdrawal of the colonoscope to optimize mucosal visualization and decrease the number of missed polyps.”
Gweon, et al., conducted a randomized trial at three university hospitals. “For patients in the study group,” they wrote, “polypectomy was performed together with careful inspection during both colonoscope insertion and withdrawal. In the control group, polyps were inspected and removed only during colonoscope withdrawal. The primary endpoint was the ADR [adenoma detection rate], which was defined as the percentage of patients with ≥ 1 adenoma.” What they found was that the ADR was similar in both groups, with a polyp miss rate of 2.1 percent in the control group.
Their conclusion? Paying attention pays off. “Polypectomy and careful inspection during both colonoscope insertion and withdrawal did not improve the overall ADR compared with standard colonoscopy.”
Bleeding is often a factor during polypectomy. Janik found that cold-snare polypectomy (CSP) results in less bleeding than hot-snare polypectomy (cautery), making CSP safer. Katagiri, et al., conducted a single-center, prospective, randomized controlled trial, examining whether epinephrine-added saline could influence resection time. What they found was that out of 261 lesions, epinephrine “shortened the time for resection by shortening the time to cessation of immediate bleeding compared with conventional CSP in colorectal polyps ≤ 10 mm.”
Another factor in accurate polypectomy is the utilization of water and/or gas—generally carbon dioxide—to expand the colon so clinicians can more readily analyze the mucosa during withdrawal. Unusual anatomical structures can present problems in this regard: redundant colons, which present with excessive looping, and colons with severe angulation, generally on the left side, can make examination challenging.
Commonly used techniques to cope with this challenge include water immersion (WI) and water exchange (WE). In both techniques, water is infused into the colon while inserting the colonoscope to the cecum. During WE, the water is aspirated during insertion, while during WI the water is aspirated during removal. Both are effective when paired with gas.
Joseph Anderson outlined a third technique, total underwater colonoscopy, that can be especially helpful in colonoscopy for those with anatomical challenges. “Water can distend the colon so that it is actually narrower and shorter than when gas insufflation is used,” he wrote. “In addition, water has the advantage of weighing down the sigmoid, especially in the left lateral decubitus position, allowing for a straighter and less redundant sigmoid.”
Anderson added that he uses this technique when he encounters “frequent looping that does not respond to abdominal pressure, colonoscope stiffening, or change in position.” Shutting off the air and infusing water allows him to complete the insertion.
Water acts as a lubricant, Anderson wrote, and has the added benefit of not causing spasms as air does. When working with a patient who has a severely angulated sigmoid colon, a clinician might be tempted to pump air into the lumen to help facilitate visualization. Anderson wrote that “water can distend the colon, allowing for visualization of the lumen without maximally distending the lumen similar to air, which can exacerbate the angulation.” Another benefit to water is it can help prevent baro-trauma to the cecum.
A side benefit to water, Anderson noted, is that it helps patient comfort. “Meta-analyses have shown that patients who have unsedated or minimally sedated examinations with water experienced less pain, required less sedation, and were more likely to have examinations that were complete than those who had the colonoscopies performed with air.”
When he’s performing unsedated or minimally sedated exams, he observed, “I routinely use water immersion beginning at insertion with the air valve turned off. I find this particularly useful in older, thinner patients, especially women. In addition, in patients with multiple comorbidities, cecal intubation often can be achieved safely with minimal sedation.”
Another benefit is thatwater can help aid in adenoma detection, although some clinicians may argue the point. “Because water does not fully distend the lumen, flat polyps may be easier to detect because they may not completely flatten as compared to the use of gas for insufflation,” Anderson wrote.
Where water could become a real asset is in endoscopic mucosal resection (EMR). Because polyps have more of a tendency to float in water, they may be easier to see. They also tend to “float into the snare,” according to Anderson. “Polyps also are more likely to appear protruding underwater, as opposed to flat with gas insufflation. Because water has a magnifying property, UEMR may allow for easier delineation of the polyp’s border, also facilitating complete removal. Underwater may be safer than traditional EMR using air because the lumen may not be as distended and therefore the colonic wall may not be as thin as when gas is used.”
But underwater colonoscopy isn’t all perfection. The use of water can lengthen the procedure time—particularly on insertion. And while water can (obviously) improve bowel prep, it can cause a whitish mucus that’s difficult to remove. There’s some question as to the physiological effects of a large amount of water introduced into the colon, but Anderson cited two studies indicating no safety issues with the process. “Water infusion does not appear to alter serum electrolytes or vital signs.”
Polypectomy Best Practices
According to the American Gastroenterological Association, the AGA “Clinical Practice Update on Appropriate and Tailored Polypectomy: Expert Review” was published to give “timely guidance on a topic of high clinical importance to the AGA membership.” Its best-practices recommendations start simply: “A structured visual assessment using high-definition white light and/or electronic chromoendoscopy and with photodocumentation should be conducted for all polyps found during routine colonoscopy.” And of course, polyps should be inspected closely for evidence of submucosal cancer.
The next recommendation is to use cold-snare polypectomy for small polyps (less than 10 millimeters in size). If polyps are truly tiny (1–3 millimeters), cold-forceps polypectomy is an acceptable alternative. The authors do not recommend using hot-forceps polypectomy.
For intermediate-sized polyps, AGA authors expect that clinicians are “familiar with various techniques, such as cold-and hot-snare polypectomy and endoscopic mucosal resection, to ensure effective, safe, and optimal resection.” In addition, they advise using lifting agents or underwater endoscopic mucosal resection (EMR) to remove intermediate sessile polyps.
Serrated polyps need cold-resection techniques, and for polyps with difficult margins, submucosal injection is recommended.
The authors recommend hot-snare polypectomy for pedunculated lesions larger than 10 millimeters. Practitioners should have a full understanding of “the endoscopy suite’s electrosurgical generator settings appropriate for polypectomy or postpolypectomy thermal techniques.” The AGA advises against using clips to close holes for polyp sites smaller than 20 millimeters. And if the polyp is 20 millimeters or larger, is recurrent at the site, or has a challenging location for polypectomy, refer to an endoscopy center.
Lesions such as these that may require referral should be tattooed for future placement. “Tattoos should be placed in a location that will not interfere with subsequent attempts at endoscopic resection,” they wrote.
And if you’re seeing clear evidence of submucosally invasive cancer in a nonpedunculated polyp, the AGA recommends an immediate referral for surgical evaluation.
Make a Hole
Endoscopic mucosal resection, or EMR, has become an effective tool for removing larger colonic polyps, obviating the need for traditional surgery. EMR is popular because of its higher efficacy and patient-satisfaction rates, quicker recovery, lower costs and complication rates, and “the ability to preserve normal gut function,” according to the Mayo Clinic.
But removing large polyps is challenging at best. Practitioners often inject a 0.9% sodium chloride solution, enhanced with dye, to help elevate the polyp and make removal easier by creating a cushion between the mucosal layer and muscular layer. This helps prevent thermal injury and lowers perforation risk. But saline is rapidly absorbed into the body, which means practitioners often must inject more solution to finish the procedure.
To deal with this challenge, GI professionals have long come up with other “homemade” solutions to help elevate polyps. Ultimately this led to the development of FDA-approved gels and other submucosal injection agents. One of the most popular, SIC-8000, was approved in 2015 as a Class 2 medical device, and other gels quickly followed— notably, without much clinical data—and hit the market. ORISE was particularly well received as it was a darker color than SIC-8000—especially beneficial during EMR.
However, problems quickly arose with its use.
Esnakula, et al., wrote in a case report, “ORISE Gel may potentially hinder the histologic evaluation of mucin-predominant lesions such as mucinous adenocarcinoma or adenocarcinoma with mucinous component. Hence, the gastroenterologist needs to report the use of ORISE Gel on the requisition form or endoscopic report. In addition, pathologists must be aware of the histologic appearance of ORISE and be prepared to use additional stains to prevent overinterpretation of such findings in the ER specimen.”
It gets worse. Mendelson, et al., examined how lifting agents can present as a colonic mass that mimics cancer. “Lifting agent granulomas have become a routine endoscopic technique to help achieve full resection of flat/sessile colorectal polyps and early-stage cancers,” they wrote. “This report confirms that these granulomas exhibit colonic transmural involvement. Sub-serosal blood vessel involvement is reported for the first time. It is important to recognize the unique characteristics of these new synthetic lifting agents. Their propensity to develop a mass-forming granulomatous reaction has the potential to mimic invasive adenocarcinoma clinically, radiologically and pathologically. This can significantly impact patient care and management both clinically and surgically.”
And in a 2023 editorial, Rex and Lahr detailed numerous clinically significant adverse issues with ORISE. They wrote, “ORISE appeared to persist in the tissue, and biopsies from specimens taken at a later date showed an eosinophilic material accompanied by a multi-nucleated giant cell reaction.”
“Purported advantages of submucosal injection before resection have sparse evidential backing,” Nett and Binmoeller wrote. “Poorly performed submucosal injection can make EMR more challenging and may increase the risk of certain complications.”
But EMR is where underwater colonoscopy can really shine. “Compared with reported outcomes of conventional EMR, underwater EMR achieves high rates of en-bloc resection and low rates of lesion recurrence,” they wrote.
Anderson cited a randomized trial showing the effectiveness of underwater EMR for smaller polyps. “Applying the technique to smaller lesions may be a good starting point for endoscopists who want to try UEMR,” he wrote.
Closing the Hole
Clinicians have several tools in the kit when it comes to fixing the gap created by a polypectomy. In an ideal world, the gap would close itself and everyone would go home happy. But in the real world, practitioners often use clips, sutures or staples to bring the edges together again.
But what happens when the polyp is irregular, the hole large, or the spot in question difficult to reach?
A novel through-the-scope suturing system was put through its paces in a 2021 multicenter study. Eight medical centers located in the United States examined the system’s feasibility and safety, as well as secondary considerations such as “assessment of need for additional closure devices, prolonged procedure time, and technical feasibility of performing the procedure with an alternative device(s).”
The authors concluded that the device was safe, efficient and worked as intended to close large and irregular defects that were difficult or impossible with established devices.
A multicohort retrospective study by Bi, et al., examined the rate of delayed bleeding with a through-the-scope suturing device (TTSS). The authors found that “TTSS alone or with TTSCs was effective in achieving complete closure of all post-EMR defects, despite a large lesion size. After TTSS closure with or without adjunctive devices, delayed bleeding was seen in 3.2% of cases.”
While polyps and their malignant offspring continue to present challenges to GI professionals, innovation and substantive research help make the job easier and more rewarding, improving the surgical experience and patient care.

### AfterCare: Learning to Let Go
I wasn’t trained for this.
All of us in medicine were taught to battle death to the final breath. We would debate euthanasia practices of foreign climes and those of our veterinarian colleagues with occasional envy and confusion on how one might know when the time was right to let go. We all heard of our hospice nurses who pointedly cautioned their terminal, in-pain patients on how much narcotic not to take.
I have a history of holding on too long. Starting in medical school  with  fur-babies  to  whom  I  administered  daily subcutaneous  saline,  insulin  and  home-produced  renal diets, or debated diagnostic laparotomies to determine feline Crohn’s versus lymphoma (the latter more likely), I acknowledge that I frequently held on too long to my loves for my own selfish needs.
My granddad (we called him GrandDOM, for dirty old man— he wasn’t, but did share a love of pull-my-finger humor and “break glass in case of emergency” corncob bathroom decor) died after a six-month battle with metastatic pancreatic cancer while I was in my first year of GI fellowship. My mother practically needed to pry him from the hospital, as they wouldn’t release him with an indwelling biliary catheter and a fever of unknown origin; they wanted to continue rotating antibiotics and consider chemotherapy in a deeply jaundiced 86-year-old. Thank goodness mom was brave and bold, and kept GrandDOM in comfort in their home for his final months. I agreed that further hospitalization was futile, but I was frightened and heartbroken that my beloved gastroenterology could not make him more comfortable or buy him extra time.
I lost my dad to disease related to his tobacco use; despite his own father succumbing to mouth cancer, Dad simply couldn’t quit smoking. He had a quadruple bypass and still didn’t quit, smoking on the down-low while attending his model- train club. Laryngeal cancer? I’m afraid that he continued his burning cancer sticks, even via his laryngeal stoma — I wince at the mental image. I’m afraid he couldn’t see the point of nicotine withdrawal — he later said that he fully expected to die as early as his father had from “tobacco-use disorder” (a pretty sanitized name for a difficult-to-break, nasty addiction) and was woefully surprised to last about seven more years after his laryngectomy.
I was alerted by a phone call from Mom that Dad had visited the ED the previous day — an unheard of occurrence for my stoic pop — for weakness and shortness of breath, and he was found to be profoundly anemic. He refused hospitalization or transfusion. I hopped an evening flight from Virginia to Florida to fix this apparent GI issue; after all, who better than a gastroenterologist to manage anemia?
We took my pallid and weakened Dad, who didn’t make his usual objections, back to the ED, where they confirmed his profound anemia and admitted him to the floor. He had just arrived to the room and had yet to be checked in by the staff when he suffered a respiratory arrest, and as the sole person in the room who knew the relevant medical history, I found myself presiding over the code. Dad was intubated and moved to the ICU — precisely where and how he had told me he wished never to be.
With conversation with the intensivist and Dad’s internist, and looking at his profound acidosis, the three of us decided we would give Dad one hour on the ventilator to reverse the acidosis and hopefully benefit from deep suctioning. If there was no improvement, we would discontinue the ventilator — a bit belatedly but in accord with Dad’s wishes — and allow him to go.
The repeat blood gas showed no improvement, so Dad’s laryngeal stoma was extubated, and the family received liberal bedside privileges in the ICU. We gathered at bedside and shared stories of growing up with our complex and brilliant father. And his death lingered.
Several times I was approached by the intensivist warning me that if he remained alive by morning he would be moved to a step-down floor, and consideration for transfer to a nursing home under hospice would begin. The nurses, being supportive, would murmur in my ear that if I would like, they could give a dose of IV morphine to help with “anxiety from air hunger.” I simply couldn’t give the order. Dad appeared comfortable, the outcome was a forgone conclusion, but I simply couldn’t give the okay to euthanize him. He died about 0200, directly after my younger brother Michael had left the hospital to get my mom home.
I am faced with loss again. My mom is a healthy 90 years old but is beginning to “slip a bit,” mentally. Her internist says it’s not dementia, but rather, normal aging. Mom insists this summer she wants to return to her summer home in the in the mountains of North Carolina, with its twisty-turny roads, despite a recent diagnosis of wet macular degeneration in her
one remaining good eye, requiring intraocular, anti-vascular shots monthly. Her friends have all died or moved down to the flatlands. At her Florida condo, her friends have died or moved on. We, her children, have carefully started to discuss a retirement home close to my brothers in Orlando, with in- house activities, transportation and nearness to the family (and to the great-granddaughter with a second in the oven). But it’s difficult; I believe her resistance is concern over loss of autonomy and change.
I just returned home from a major blessing: the opportunity to travel with my mom on a 14-day river cruise of the Netherlands and Belgium. It was wonderful to travel with Mom, my older brother, Robert, and my sister-in-law, but because we were outside of Mom’s normal venues, her confusion was more obvious. If I didn’t keep her in reach on our walking tours, she would head off in a random direction. She became trapped in two travel bathrooms (one airline, one tram station), unable to unlock the door and needing assistance to exit. I mislaid her for fifteen endless minutes in the crowded Keukenhof flower gardens when she was swept away in a different tour group.
The others on our tour were kind with her, gently tapping her shoulder to direct her and waving her ahead to board buses and boats. On our return home, both she and Robert contracted COVID-19; Mom’s case was moderate, and she became confused and disoriented in her illness, although not hypoxic or in need of hospitalization. My younger brother, Michael, drove to Daytona to help assess her, participate in an urgent telehealth appointment, and bring her to his Orlando home for close watch. She has since recovered, although she has a persistent and concerning hacking cough. She will delay her return to North Carolina, but instead plans to come stay with me in Virginia for a bit until she is better before proceeding to what I believe will be her final summer in the mountains.
So I’m faced with an upcoming inevitable loss of love — akin to a slow-moving freight train approaching where our family sits, stuck on the tracks. However, my own age seems to have birthed some degree of wisdom; I can permit feeling sorrow without erecting a wall of science between me and the upcoming loss. I have learned to embrace the sadness and not buffer it.
I am learning to let go.

### TechTalk: One Direction
Is your facility challenged by a less-than-ideal flow in the endoscope-reprocessing workspace? Never fear—we’re here to help. This column will explore workflow, physical separation of spaces, equipment placement and efficient processes.
Challenges with Endoscopy Reprocessing Areas
Endoscopy reprocessing areas in an outpatient setting are often challenged by space (or lack thereof). Typically, the areas are retrofitted into an existing location that often has inadequate room for all the equipment necessary to clean and high-level disinfect scopes. When dealing with existing spaces, it’s critical to reduce the risk for contaminating processed scopes.
Whenever possible, the endoscope-reprocessing areas should be separated. However, budgetary constraints, square footage of buildings, and the required areas for patient care often make this almost impossible. When separation of spaces is not possible, it’s essential to understand what is required to ensure small spaces are meeting minimum standards to reduce the risk of contamination, transmissions, and infections to patients and employees, the environment, and community.
Workflow
An adequate area should have a unidirectional flow, with good distance between spaces used for the various stages in processing. There should be sufficient space for workflow patterns that start with a soiled holding area and end with a high-level disinfection area—and finally, storage. The area should be designed to reduce the risks of bloodborne pathogen exposure to employees and devices.
There should also be precautionary measures to prevent cross contamination of processed scopes and processing equipment. When reviewing the space, assess how to prevent employee- related injuries (e.g., from having to lift or carry heavy items unnecessarily) and the possibility of microorganism growth in the reprocessing area.
Additional considerations include ensuring that all work sur- faces, ceiling tiles and counters are nonporous; corners should be rounded off to prevent injuries; and all work areas should be height adjustable or positioned to meet the average height of most employees. While washing and decontaminating devices, technicians must stand for prolonged periods of time, so anti-fatigue mats should be used to help prevent worker injuries.
Personal protective equipment (PPE)—impervious gowns, face shields, masks, gloves, bouffant caps and shoe covers— should be located at the entrance to the area. Shelves or closed cabinets can be placed outside the entry door or as soon as one enters the area. If stored inside the processing area, PPE should be contained to prevent it from becoming contaminated. All equipment and supplies should be stationed and stored in such a way as to reduce the number of times the technician needs to move back and forth. Everything in the room should be set up to induce a single directional flow pattern when the technician enters.
Physical Separation of Spaces
In a one-room reprocessing area, sufficient space allows for all tasks to be performed with ease. Reprocessing functions should not be performed in the same room as procedures; the only disinfecting process that can be performed in the procedure room is point-of-use cleaning. Policies and procedures should outline how point-of-use pre-cleaning of endoscopes should be performed, how scope accessories are cleaned, and how endoscopic components are transported from the procedure room to the reprocessing area. Flexible endoscopes should not be stored in procedure rooms.
The processing area should be a restricted space that is limited to designated personnel only. A sign reading “Restricted Area, PPE Required” should be posted outside of the door (in the case of a one-room setup). Otherwise, a sign requiring PPE should be posted on the entry door to the scope-cleaning room. A unidirectional flow should be considered when transporting devices from the procedure room to the decontamination area. A hand-off process (delivering items from one point to the other) of the soiled device to the processing technician should be developed and written in the policy.
Although physical separation for each process is preferred, it is not always possible. Partitions or dividers may be needed to reduce potential splash between spaces. For example, a plexiglass partition at least four feet high and four feet wide can be installed next to the final rinsing sink in the decontamination space to separate the contaminated space from the clean space.
The clean space can continue as an inspection station, cleaning verification space, and staging area until the scope can proceed to high-level disinfection. Then there should be an adequate space for drying scopes with instrument air. Perform a risk assessment to verify that all process steps follow a unidirectional workflow pattern, fill potential gaps, and identify potential risks and exposed areas of opportunity that need immediate correction.
Equipment Placement
Daily tasks require specific tools and equipment that may take up counter space and limit how that area can be utilized. When considering the placement of equipment necessary for endoscope-device reprocessing, the person organizing the space should analyze intended use for each piece of equipment. Reading all operational manuals and manufacturer instructions will help identify the equipment specifications and space required to use the equipment properly.
For instance, when cleaning flexible endoscopes, the Association for the Advancement of Medical Instrumentation (AAMI) recommends a sink with a minimum of two wells — three wells are preferred. Each sink should be long and deep enough for technicians to place the endoscopes into the sink well, loosely coiled, without causing damage. Most flexible GI endoscopes need a sink at least 36 inches wide and about 8-10 inches deep (AAMI, 2017). Other processing equipment should be assessed for the required space and for service or repairs.
When starting the decontamination process, there should be space to perform leak testing of the scopes. Space is also needed so technicians can visually inspect the flexible endoscopes under 10x lighted magnification. When counter space is limited, installing shelves or brackets can help free space where a leak tester and magnifying glass can be stationed.
Automated device flushing systems often require a significant amount of space. When considering purchasing, it’s very important to know how much total space is required and to assess where the flushing unit can be placed so that it does not take vital space needed for staging scopes and other supplies.
For clean workspaces, create a designated area to store supplies, manufacturers’ instructions for use (IFU), operational manuals, detergent, safety-data sheets and chemicals.
Most facilities are no longer manually high-level disinfecting their scopes; however, facilities that use manual soaking stations for high-level disinfection (HLD) of medical devices should have a designated area near a plumbing drain where technicians can pour and empty chemicals without creating splash or having to lift and carry heavy soaking and rinsing pans to a sink or drain. Placing the manual soaking station near a drain can prevent work injuries and chemical-exposure hazards.
When manual soaking stations cannot be located near a drain, it’s a good idea to use small lakeside carts with wheels so that the technician can slide the chemical- or water-filled pans onto the cart and push the cart to the drain and empty them safely. For employee safety, emergency eyewash stations and handwashing sinks should be in a designated clean area of the room, preferably by the exit. Eyewash stations should never be installed on the decontamination sink as this is considered contaminated. Employees should never flush their eyes or perform hand hygiene in a decontamination sink.
Automatic endoscope reprocessors (AER) that perform HLD are considered a clean activity, and so should never be placed next to or side by side with the decontamination space. At least four feet of distance is recommended. Although not ideal in areas where separation is not possible, partitioned walls can be installed to separate the decontamination space from the clean space. AAMI provides guidance and recommendations on how to properly separate one-room reprocessing areas. Storage cabinets should be placed and positioned in clean areas. Each scope in inventory should have enough storage space to prevent potential damage to the scope. Nothing else should be stored in the scope storage cabinet unless validated by the scope storage manufacturer.
Efficient Process
Dealing with existing spaces can be quite challenging. The most efficient process is mapped out in a way that allows technicians to be efficient, with all the needed equipment and supplies in the correct order, and all tools and resources readily available. Additional improvements can be made by utilizing color-coding systems to identify various brushes or supplies for specific pieces of equipment. Labeling and identifying each storage container and setting up par levels to keep inventory and supplies controlled will help technicians be more efficient as well.
All logbooks, manuals, safety-data sheets and paper materials should be stored in covered cabinets but identified with water-resistant labels (i.e., P-touch labels). Wipeable charts for cleaning processes, and information on how to start AER cycles and use the leak tester or flushing device, can be posted on walls or in a binder for quick reference.
Creating a highly functional space in the smallest areas can reduce the risk of hazard, make the area more user-friendly and provide safe and effective ways to reprocess flexible endoscopes properly. Patient and employee safety can be greatly reduced when proper assessments, planning, reviewing and organization of space is performed.

### Asset Utilization
How often do you experience stress or anxiety the day before a busy procedural schedule? Have you ever wondered if you have enough colonoscopes or if any devices have been sent out for service? If so, has loaner equipment arrived? Is the department efficiently staffed to manage the patients, doctors and equipment?
How often do you think about the number of assets in your department? Assets are all the endoscopes needed to provide safe patient care. How do you know you have enough assets to support the procedures on your schedule? If endoscopy professionals across the country were asked if their department has enough equipment, many would say they do not. GI procedures are increasing, and according to Paone (2024), the leading causes of higher volumes are a backlog of patients who delayed procedures during the pandemic, a new recommendation for colorectal cancer screening to begin at the age of 45, and an aging population.
How does a department get ahead and ensure enough equipment is available to accommodate procedural volume? Before we get to the “how,” let's review why it is important to have sufficient inventory.
Form and Function
The Centers for Medicare & Medicaid Services (CMS) requires hospitals to ensure supplies and equipment are maintained to an acceptable level of safety and quality for patient use (Centers for Medicare & Medicaid Services, Department of Health and Human Services, 2017). These guidelines are based on a federal statute called the Code of Federal Regulation (CFR), which governs areas in healthcare that pertain to patient care. CMS and other accrediting agencies conduct surveys to ensure healthcare facilities effectively meet required standards and regulations.
The CFR spells out standards and expectations for how facilities should function to keep patients safe, stating that hospital have three responsibilities: 1) Facilities should have enough supplies on hand to meet day-to-day needs as well as what would likely be needed in the event of an emergency; 2) Facilities should have adequate provisions to support and maintain supplies; 3) Facilities should ensure supplies are stored in a manner to protect them from theft, contamination, damage and deterioration. This responsibility applies to equipment too (Centers for Medicare & Medicaid Services, Department of Health and Human Services, 2017).
When we think about how to ensure equipment is safe for patient use, it is good to think about it from a quality-management perspective. Quality management is an ongoing process — a series of actions or steps taken in order to achieve a particular end (Seelbach & Brannan, 2023). Understanding how equipment is used is known as asset utilization, and it’s part of a quality-management process. Under-standing and implementing the quality-management process is important in the perioperative space because things change very frequently. For example, priorities shift, procedure volumes increase and decrease, and employees come and go. Using a quality-management approach can provide insight into needed changes to your inventory that will positively impact your department and facility. Hopefully, by using a quality-management strategy, the frequency and severity of asset damage will change as well.
There are various types of flexible endoscope models that are used in the perioperative space. Specific situations, such as opening a new department or upgrading to a new generation of equipment, require assessment of how much inventory is needed. Over time, that initial amount can change. Perhaps you started with enough, but how do you determine when to add more?
One approach is to consider how long it takes to clean, inspect, disinfect or sterilize, and dry items, along with the types of reprocessing equipment and specific cycle times being used. Another approach is to evaluate the physical size of your department. Do you have enough space to manage all flexible endoscopes in your inventory? Is the layout and flow conducive and efficient? A third approach is to determine the number of staff needed to manage inventory. How many people are needed to turn around flexible endoscopes safely in a timely manner? Many times, these factors are used to determine the amount of inventory needed initially but may not be used to determine if inventory is sufficient on an ongoing basis.
How many assets do you really need? According to Philip Doyle, Olympus executive director of marketing, “Olympus recommends that each scope only get around 300 uses per scope per year.” (TechNation, 2023). Without the right number and mix of equipment, procedural turnover times can decrease, which can impact efficiency and other factors such as staff overtime. Understanding not only how much inventory is needed overall but how much of each type of flexible endoscope model is needed can be challenging.
Determining environment-of-care requirements in departments such as sterile processing and endoscopy is important. One of the biggest challenges facilities may have is inventory storage. Having adequate space is vital. As procedural volumes increase, it is important to evaluate space in the department to ensure there is enough room to store an increase in inventory. It is also important to evaluate the types of containers needed to transport — and cabinets to store — flexible endoscopes. For example, are transport containers designed to support flexible endoscopes from shifting and being damaged? Do you have the right type of cabinets to properly isolate and secure flexible endoscopes? Is storage space organized and easy to navigate?
Evaluating workspace is another factor to consider. Having an adequate setup in the decontamination and reprocessing area is critical to ensure efficient and effective cleaning. Some flexible endoscopes may require extended cleaning or soak time, which can tie up a sink and create a backlog. When space is limited, it can be easy to stack flexible endoscopes on top of each other, but this can potentially damage the endoscopes and create the need for replacements.
Routinely evaluating departmental environment provides insight into continuous improvement measures. When procedural volume is high, more time is needed to sufficiently clean everything. Evaluating the specific types of cleaning cycles being used can be very insightful when determining whether inventory is sufficient. Leak testing, manual cleaning, inspection, HLD/sterilization and drying all take time. The longer the reprocessing time, the more inventory you may need to support procedural volume. Always refer to the manufacturer’s instructions for use (IFU) for cleaning requirements for each flexible endoscope model to determine what cleaning steps should be used.
Part of implementing quality-management processes requires evaluating inventory. It can be beneficial to consider the impact of insufficient inventory on individual departments, the facility as a whole, and the patients being cared for. It can be challenging to turn equipment over quickly. This type of pressure can increase staff stress and potentially lead to missing an important step — or worse, cutting corners. Increased wear and tear on inventory from repetitive use and reprocessing can result in increased damage and repairs and result in equipment not being patient-ready when needed. Ultimately, lack of sufficient inventory can lead to the need for bringing in outside equipment (referred to as loaners). Loaner equipment is not an immediate solution. For example, if you have a flexible endoscope that is sent out for repair and a loaner device is needed, most likely you will not receive that device until the next day at the earliest. Once received, the loaner item should be fully reprocessed before it is used, which also takes time.
Nurses Count
Many facilities experience staffing challenges. McKinsey & Company (2022) predicts a potential shortfall of 200,000 to 450,000 registered nurses available for direct patient care by 2025. Staff are crucial to the success of a facility and play a critical role in on-time procedural starts and positive patient outcomes. Once staff are hired, training and education are needed to set teams up for success. Initial training, competency validations and ongoing education are all part of the process. Ensuring departments have the right number of staff to manage inventory for procedural volumes is important.
The last two years have seen updates to guidelines set forth by the AORN and the Association for the Advancement of Medical Instrumentation (AAMI) regarding reprocessing of flexible endoscopes. These updates include a heightened emphasis on visual inspection, cleaning verification, leak testing, drying, and the need for delayed reprocessing.
Visual inspection should be completed for all flexible endoscopes to ensure they are clean, free of damage and functioning as intended (Klacik, 2022; Kyle, 2022). Having enough inventory on hand reduces the need for quick instrument turnover and the potential for missing something during reprocessing. Effective and efficient reprocessing could be impacted because visual inspection, cleaning verification, lengthened leak testing, and drying time all increase the amount of time it takes to reprocess devices.
Without the right number and mix of flexible endoscopes, efficiency of the reprocessing cycle could decrease, resulting in slower procedural turnover times and increases in staff overtime hours. It’s important to evaluate the mix of models in your inventory to ensure you have enough for the different types of procedures being performed. For example, perhaps a doctor prefers to use a pediatric colonoscope for all patients, versus using an adult colonoscope. In that situation, how is inventory impacted? If only pediatric colonoscopes
are being used, adult colonoscopes are being used less. This can increase staff stress from needing to turn the pediatric scope over quickly and could potentially result in delayed availability throughout the day. Even if you have a mix of models, preferences such as this can lead to overutilizing certain models and increased repairs. The challenge is that inventory and volume are not apples-to-apples. Inventory does not always meet procedural volume needs.
A Systematic Approach
An VVV-tracking system can provide insight into how often equipment is being used. Tracking systems may be used to evaluate department productivity, cleaning and assembly times, and the total time needed to complete all reprocessing steps from patient use to patient use. Scanning items into or out of high-level disinfection (HLD) or sterilization can provide insight into procedure volumes. Each time an item goes through HLD or is sterilized, it can be aligned with each time it was used. Year-over-year analysis helps determine overall increases in inventory use and can help determine how to best plan for spikes in procedural volume at specific points in time. For example, some institutions may do more procedures in November and December than other months of the year.
Another approach would be to identify a specific model of flexible endoscope and evaluate its usage month by month. A higher number of procedures performed in a particular month using that specific model may warrant adding more of that type of model to accommodate for higher volume months.
See bar graph below for an example.
Screenshot
Reviewing average uses per day in one month will provide insight into daily average use. Evaluating how many times a specific model was used in the month, the number of that model in inventory, the number of operating days in the month, and the average use per day in that month can tell a story. For example, when evaluating a pediatric colonoscope model, you may determine that two or more uses per day justifies adding another model to your inventory. When
considering the length of the procedure, total reprocessing time, and dry time, adding one or two more of this type of model may be necessary to ensure enough inventory is available.
Every facility will be different. The busiest days are typically when stress is higher and turnover times need to be quicker. It may also be beneficial to drill down further and look at the day or days of the month when more procedures are being done or when a specific doctor works on a specific day. When evaluating asset utilization in this manner, it may be beneficial to have additional equipment to meet the needs of those specific high-volume days. When you analyze usage, you have insight into what items are in demand and what items are needed, which helps prioritize items for budgeting purposes.
See pie chart below for an example.
Routinely evaluating usage can help identify which models you need more of and help you achieve an apples-to-apples comparison between inventory and procedural volume. Right-sizing inventory may not happen quickly, but having data that clearly identifies usage can help support the need for adding inventory and enable you to plan ahead. For example, if procedural volumes are trending upward by 10%, you may consider adding 10% more inventory. Having data to justify the need and to support acquisition drives value for departments, the facility, and the patients served.
Let’s circle back to the quality-management process. Look at the department environment and consider whether it supports the volume and type of equipment being reprocessed, whether you have the right number of staff and can provide needed training and education, and whether you are experiencing inventory-related challenges in one area more than another. Identify, track and trend key performance indicators (KPI) to obtain inventory specific data. For example, KPIs might include reducing the number of HLD or sterilizations for specific models month by month, reducing repair frequency by 20%, or improving on-time procedure starts by 90%.
As you assess your inventory, set measurable indicators to determine if the strategies implemented are successful. Using data analysis to evaluate inventory usage can be beneficial. Increased usage should lead to adding inventory. Make reviewing inventory a routine task and be aware of factors that could lead to needing more equipment, such as adding a new doctor or opening a new room, which leads to increases in volume. Routine evaluation drives changes that will enable you to plan ahead.
Understanding asset utilization can help justify the need to supplement inventory to adequately support increases in procedural volume and help ensure safe patient care.

### Ascension St. Elizabeth Day Surgery Center
Our team is a true family (minus the dysfunction).
We work at Ascension St. Elizabeth Day Surgery Center in Menasha, Wisconsin, and get along very well on the clock and have fun outside of work, too. Our group consists of three board-certified gastroenterologists, nine registered nurses and five technicians.
As most in our industry know, adenoma detection rate (ADR) is a quality measure for endoscopy facilities. ADR looks at the rate at which a physician finds precancerous polyps during a screening colonoscopy. A physician’s ADR has become a gold standard for quality. The American Society of Gastrointestinal Endoscopy has determined that a minimal benchmark rate should be 25% average overall. Our three physicians have ADRs greater than 50% overall. We are all very proud of this and love bragging to patients about it.
We have a fairly large service line, including colonoscopies, gastroscopies,  Barrett’s  ablation, hemorrhoid ligation with the HET system, reflux services including Bravo and DigiTrap- per, esophageal and anorectal manometry, endoscopic ultra- sound (EUS), and endoscopic retrograde  cholangiopancrea- tography. Additionally, one of our gastroenterologists recently became board certified in obe- sity medicine and is starting to do Orbera intragastric weight-loss balloons, which we are super excited about!
Our pre-op and recovery nurses do a fantastic job teaching patients how to increase fiber in their diets, the importance of probiotics, when to best take their reflux medicine, and the importance of a repeat colonoscopy if polyps were found or if they have a family history of colon cancer. We also coordinate same-day CT scans for a newly diagnosed mass and any additional labs that need to be drawn, all while providing emotional support for the patient and their family.
One of our gastroenterologists, Dr. Sudeep Sodhi, M.D., gives a biannual talk (pre-COVID) called, “We Are What We Eat: A Gastroenterologist’s Perspective.” He opens his talk with a disclaimer, stating that if the audience members listen to him, it will be bad for his business. He—along with his partners—truly cares about the health of our community.
My colleague Sara Clark, RN, MSN, says, “The unique cohesiveness of our GI team is apparent in everything we do. Our goal is to ensure patients feel comfortable and well cared-for during their visit. From preadmission through discharge,  our  exceptional  teamwork  is  evident  every step of the way. We all understand the importance of one another and appreciate what each staff member brings to the table. The synergy is undeniable. Not a workday goes by that I don’t hear a comment about our team’s cheerfulness, love of our work, or exceptional care with a smile (which was even more obvious before we had to mask every day!). Work isn’t work when you love what you do and those who surround you. I truly feel blessed to have such a remarkable work family.”
Another team member, Vikas Khullar, M.D., says, “With three board-certified physicians who believe ‘there is no I in TEAM’ and work hard to provide high-quality, cost-effective and patient-centered care, I can say our GI team is the best. Be it day or night, we all enjoy getting up and taking care of patients, while at the same time having fun. Each member is treated as an integral part of the team, providing education and support, not only to patients, but also to each other. Outside of work, we get together to have Liver Rounds/
Happy Hour (it’s Wisconsin, after all!) and various team activities. I am proud to be a part of this awesome team!”
We all believe that a team that plays together, stays to- gether. Almost everything we do outside of work has a cancer-awareness flair. We have done marathon relays wearing shirts  that  were  specifically designed to promote screening colonoscopies.  We  ring  bells for  the  Salvation  Army  at Christmastime, hand out pens with colon-cancer ribbons on them, and encourage patrons to come see us at work. We have pedaled around our downtown on a Pedal Pub, holding up signs that read, “Clear liquids can be fun,” and telling everyone we meet to make sure they get their screening when it is time.
Every year we come up with a slogan to promote colon- cancer awareness, and the team gets together and dresses up for a photo shoot. We have done a superhero theme (saving lives), boxing (knocking out cancer), and plumber (flushing colon cancer down the toilet). For a football theme (tackling), we all wore the #50 jerseys from our area high schools to signify the importance of screenings at age 50. Most recently, we featured a fire theme, because we want nothing more than to extinguish colorectal cancer. We also make our picture into a holiday card and send it to all our referring physicians in hopes they remember to send patients for their screening.
About five years ago, two of our three gastroenterologists quit on the same day, leaving just Dr. Sodhi. We were able to hire a locum gastroenterologist to help him, but for the most part he carried the load by himself, doing most of the daily colonoscopies and gastroscopies. He also performed all the EUS and ERCP cases. He did this for two years. We were all very thankful that he decided to keep going, even when the going got tough. One of his reasons for not leaving was the people of our community.
It wasn’t easy finding someone who wanted to join a practice in small-town Wisconsin, but we were patient. Vikas Khullar, M.D., joined our team about three years ago, and he was definitely worth the wait. About a year ago, we hired Dr. Sankalp Dwivedi, M.D., to complete our team, and he has been a fantastic addition. All three of them bring something special to the table, and they all complement each other nicely. Besides being excellent endoscopists, these physicians have impeccable bedside manners and compassion, and treat staff with kindness and respect. We now have an All-Star team, and this challenging time of COVID has made us realize firsthand that every cloud has a silver lining.
If I had to sum up our team, I’d have to use the following Mother Teresa quote: “None of us, including me, ever do great things. But we can all do small things with great love, and together we can do something wonderful.”

### Disinformation
Remember the days when you felt like you knew what information to trust? Now, in an age when disinformation runs rampant, many people feel they don’t know where to turn. Is the information we consume true, false, or worse yet, purposely false?
Disinformation is different than misinformation. Misinformation is a mistake (a good way to remember that is the “mis” in misinformation is like the “mis” in mistake). Disinforma- tion, on the other hand, is false or misleading information shared with the intention of manipulation or to mislead, and it’s being spread with reckless abandon. But we can at least trust medical studies from our nation’s finest research institutions, right?
Um, yes. But note the “um.” I offer apprehension because after recent news of unfor- givable publication problems, perhaps we need more reservation than we used to have.
According to a recent New York Times article titled, “More Studies by Columbia Cancer Researchers Are Retracted,” Columbia studies were pulled due to copied data. These cases indicate that some scientific publishers are slow to address serious errors such as data discrepancies and reuse of photos.
“Scientists in a prominent cancer lab at Columbia University have now had four studies retracted and a stern note added to a fifth accusing it of ‘severe abuse of the scientific publishing system,” the article reads.
In addition, the New York Times reported that “a medical journal in 2022 had quietly taken down a stomach cancer study by the researchers after an internal inquiry by the journal found ethics violations. Despite that study’s removal, the researchers—Dr. Sam Yoon, chief of a cancer surgery division at Columbia University’s medical center, and Changhwan Yoon, a more junior biologist there—continued publishing studies with suspicious data. Since 2008, the two scientists have collaborated with other researchers on 26 articles that have been publicly flagged for misrepresenting experiments’ results.”
Since then, medical journals pulled three other studies that described novel approaches for treating cancers of the stomach, head and neck. The studies had been cited dozens of times.
“For every one paper that is retracted, there are probably 10 that should be,” said Dr. Ivan Oransky, cofounder of Retraction Watch, which keeps a database of 47,000-plus retracted studies.
Disconcerting, to say the least. We should trust most information from researchers and from universities, but clearly, we shouldn’t trust it all. We can forgive mistakes, because we all make them. But intentionally misleading? No. This research situation is gross, and that’s not disinformation.

### Not So Sweet: Artificial Sweeteners Significantly Alter Microbiomes
LOS ANGELES, California—Cedars-Sinai Medical Center investigators recently examined the potential effects of consuming non-sugar sweeteners on the composition of the stool and duodenal microbiomes. Compared to controls in the study, scientists noted significant differences in both stool and duodenal (small intestine) microbial diversity and composition. Levels of circulating inflammatory markers were also altered in participants who consumed non-aspartame non-sugar sweeteners as well as those using aspartame only.
The study is published in the journal iScience.
More than 140 million people in the United States use sugar substitutes, according to data from the U.S. Census Bureau. Sucralose, aspartame, saccharin and the plant-based stevia leaf extract are among the most popular. These artificial sweeteners are frequently used by people trying to reduce their sugar intake or lower calories from sugar for weight management. However, there are increasing concerns about the potential health risks associated with the use of non-sugar substitutes based on data suggesting they do not help with long-term weight loss and may be linked to higher risks for Type 2 diabetes, heart disease and death. There are also questions about the potential negative effects the sugar substitutes may have on the gut microbiome, which plays a vital role in overall health.
In a controlled study, Cedars-Sinai investigators analyzed and compared the duodenal luminal microbiome in subjects consuming artificial sweeteners, aspartame alone or no sugar substitutes. The stool microbiome in some of these subjects was also compared.
Investigators obtained samples from a small group of adults undergoing standard of care esophagogastroduodenoscopy without colon prep. All enrolled subjects provided duodenal luminal aspirates as well as fasting blood samples for analysis, and a subset also provided optional stool samples. Scientists analyzed the duodenal luminal microbiome in subjects consuming non-aspartame non-sugar sweeteners, aspartame only, controls, and the stool microbiome in a subset.
Artificial sweeteners are associated with a variety of changes depending on the area of the intestine. Significantly, the effects of these substances on the gut microbiome differ in the small bowel compared to the large bowel.
“Artificial sweeteners are not benign for the microbiome of the gut,” said Ruchi Mathur, MD, a professor of Medicine at Cedars-Sinai, an endocrinologist, and the lead author of the study. “We found that the richness of the bacteria in the small bowel was less in those subjects consuming non-aspartame non-sugar sweeteners when compared to controls, whereas bacterial richness in those consuming aspartame was similar to controls.
“Interestingly, when we looked at predicted metabolic pathways in these bacteria, we noted that the pathway of cylindrospermopsin, a toxin, was enriched specifically in small bowel bacteria of subjects who consumed aspartame,” Mathur continued. “This pathway is recognized for its harmful effects on the liver and the nervous system, and it is classed as a potential cancer-causing agent.”

### The Link to Zinc: Zinc Plays Key Role in IBD and 'Leaky Gut'
LONDON, England—Researchers from King’s College, in London, England, have found an association between low zinc intake and health of the gastrointestinal tract. These findings have potential implications for a third of the world’s inhabitants who are zinc-deficient.
This new research, published in Nature Communications, has found a link between the micronutrient zinc and a sensor protein in the gut that plays a role in the prevention and management of a range of bowel conditions, such as inflammatory bowel disease.
King’s Professor Christer Hogstrand led an international team that created “mini-guts” from human stem cells and mice. They investigated the role of zinc and a sensor named the “Aryl Hydrocarbon Receptor” (AHR) that helps the body react to nutrients, drugs and toxic substances in the bowel. Mice fed a diet containing zinc and a chemical from cruciferous vegetables (such as broccoli) that stimulates the AHR were almost completely alleviated of IBD. In contrast, mice fed a zinc-deficient diet received no benefit from AHR activation.
There’s a prevalence of zine deficiency in countries where diets are dominated by plant-based foods, which are poor sources of nutritionally available zinc. The discovery offers new options to manage IBD through dietary supplementation with zinc and plant-derived bioactive compounds that stimulate AHR, which are particularly abundant in cruciferous vegetables.
 

### FDA Grants Clearance for Imaging Technology That Measures Colonic Lesions
LEXINGTON, Massachusetts—FUJIFILM Healthcare Americas Corporation, a provider of endoscopic imaging and endosurgical products, has been granted FDA 510(k) clearance for SCALE EYE, a new endoscopic imaging technology.
The SCALE EYE system consists of a laser-equipped colonoscope (model EC-760S-A/L) and endoscopy support software (EW10-VM01). The system displays a linear or circular virtual measurement—or scale—over the area of interest on the endoscopy monitor.  With the push of a button, SCALE EYE aids endoscopists in estimating the size of colorectal lesions in vivo without relying on visual estimations, consumable tools, or the need for additional surgical instruments.
Traditionally, endoscopists estimate the size of neoplasms by comparing them against the size of the forceps being used to examine them, which creates risk for subjectivity. Compared to the biopsy forceps method, SCALE EYE enables more accurate, one-objective measurement of colon polyp size, a critical factor in making decisions for clinical management of neoplasms, specifically colonic polyps, as size can be an indicator of malignancy. Polyp size measurements are important for risk stratification, choice of polypectomy technique, and follow-up interval decisions.
“During colonoscopy, it is important to correctly measure the size of the polyps because it can directly impact the patient’s care pathway,” said Tai Fujita, vice president of the endoscopy division at FUJIFILM Healthcare Americas Corporation. “Early clinical results of SCALE EYE are impressive, and we’re proud that Fujifilm’s new, innovative in vivo scaling capability is demonstrating success in improving both the speed and accuracy of polyp measurement.”
Several studies have demonstrated the advantages of virtual-scale endoscopes compared to current methods in use.
“When it comes to polyps, accurate size assessment is essential to our decision-making process,” said Dr. Seth Gross, clinical chief of the Department of Gastroenterology and Hepatology at NYU Langone Health. “Polyp size is a factor in determining a patient’s recommended follow-up interval and may impact the decision on how best to achieve a safe and complete resection. We’re encouraged by early data and are excited to be the first U.S. site to evaluate SCALE EYE.”

### Promoting Sustainability
DuPont recently announced that it is launching an annual global awards program called the Tyvek Sustainable Healthcare Packaging Awards to recognize leaders across the healthcare industry who are driving sustainability throughout the packaging lifecycle.
The awards program will be open to any medical device and/or pharmaceutical manufacturer, sterile packaging manufacturer, healthcare facility, university, material recovery facility, or other healthcare company focused on sustainable packaging made with DuPont Tyvek material. Other criteria include that the initiative or solution be implemented within the last 18 months of the award application entry date and show significant sustainability-focused achievement and resulting metrics.
“Enabling the healthcare packaging industry to be more sustainable is a collaborative effort, and that’s why we have developed this awards program to recognize the spectacular achievements in this space,” said Kelly Reichert, global business director of DuPont, Tyvekm and Typar Roll Goods. “We’re proud of the essential innovations we deliver to improve patient safety and help people live long and healthy lives, and we’re pleased to shine a light on the advancements in sustainability being made across the healthcare industry.”
Interested companies should visit www.Tyvek.com/HCAwards to review more information about the categories and criteria and complete an award application online. The awards application process will be open February 1 through June 28, 2024. Following the judging process from a panel of sustainability, healthcare and packaging experts and industry thought leaders, including representatives inside and outside of DuPont.
This awards program complements the Tyvek Healthcare Packaging team’s goal to advance DuPont’s global strategy of working with global supply chains to reduce Scope 3 emissions. DuPont has already achieved a 35 percent reduction of Scopes 1 and 2 greenhouse gas (GHG) relative to 2019 baseline, surpassing its 2030 goal eight years ahead of schedule.
 
 

### New Sedation Findings: ERCP for Bile and Pancreatic Ducts
An international team of expert anesthesiologists and gastroenterologists recently determined that patients undergoing endoscopic retrograde cholangiopancreatography (ERCP)—a procedure that combines upper gastrointestinal endoscopy and X-rays to treat problems of the bile and pancreatic ducts—may be better served by deep sedation without tracheal intubation, compared to receiving general anesthesia with tracheal intubation.
The research group developed evidence-based practical guidelines for clinicians to consider, after assessing the merits and risks of both techniques. The article was published in the British Journal of Anaesthesia.
Each year 600,000 ERCP procedures are performed in the United States. This procedure is time-consuming, resource intensive and can lead to adverse events, including admission to the post-anesthesia care unit. After assessing a variety of complex patient scenarios, the group determined that for short, routine procedures with low complexity, monitored anesthesia care (deep sedation) rather than general anesthesia could lead to faster and better recovery after ERCP. The researchers stress, however, that each institution should base this recommendation on its own resources, expertise and individual patient characteristics.
The below Q&A was completed by Omid Azimaraghi, M.D., research fellow in the department of anesthesiology, and Matthias Eikermann, M.D., the Francis F. Foldes Professor and chair of the department of anesthesiology for Montefiore Health System in Tarrytown, N.Y.
What led you to assess sedation techniques for endoscopic retrograde cholangiopancreatography (ERCP)?
There is currently no standard of care to guide the choice on monitored anesthesia care versus general anesthesia for ERCP to determine which approach produces the best outcome for patients. We conducted a large retrospective analysis and published in the BJA, which favored monitored anesthesia care (Br J Anaesth. 2021 Jan;126(1):191-200.) and from there decided to consult with experts all over the world to create consensus guidelines.
Why is this an important area of investigation?
The number of endoscopic retrograde cholangiopancreatography (ERCP) procedures performed is increasing. In the United States alone, more than 600,000 ERCP procedures are performed annually. General anesthesia versus monitored sedation lead to very different effects on breathing and circulation, which can affect patients’ safety and outcomes. During ERCP, anesthesiologists and gastroenterologists also share the patients’ upper airway, such that a collaborative and consensual approach is needed.
What did you find?
Monitored anesthesia care is the favored anesthesia plan for ERCP for short, routine procedures. General anesthesia can be avoided in most scenarios. However, patients who undergo very long endoscopic procedures that carry a substantial risk of organ perforation or food aspiration should be intubated such that the procedure can be done under general anesthesia.
The consensus guidelines emphasize the value of effective interprofessional communication and also highlight that local culture and knowledge needs to be integrated into the decisions around the anesthesia plan.
How will this impact clinicians?
Monitored anesthesia care should be considered as the favored method of anesthesia in the majority of cases. We encourage gastroenterologists and anesthesiologists to communicate frequently—for example, discuss the procedures in a morning meeting—so that risk/benefit analyses can be conducted for individual patients, and clinicians can consider their experience levels, patients’ comorbidities, and procedural risks.
How will this impact patients?
Patients would spend less time in the endoscopy suite since turnover time is shorter with MAC [monitored anesthesia care]. Also, eliminating tracheal intubation eliminates some predictable signs and symptoms for the patient, such as sore throat and hoarseness.
What are the next steps, if any?
This study will help clinicians reflect on the best way for them to practice anesthesia for ERCP at their institution. This work represents the highest level of evidence currently available that can be taken into account by clinicians as a guideline for clinical decision-making.
To read more on this topic, see the article, “Consensus guidelines for the perioperative management of patients undergoing endoscopic retrograde cholangiopancreatography,” published in the British Journal of Anaesthesia.
ASGE Guidelines for ERCP
Every healthcare professional knows that guidelines from trusted industry associations can be invaluable for job performance and patient safety. Such guidelines exist for ERCP, courtesy of the American Society for Gastrointestinal Endoscopy (ASGE) Standards for Practice Committee. According to the ASGE committee members, ERCP has become an invaluable procedure in the diagnosis and management of a variety of pancreaticobiliary disorders since its introduction in 1968.
“The role of ERCP has evolved from a diagnostic to a mainly therapeutic intervention because of improvements in other imaging modalities including magnetic resonance imaging and/or MRCP and EUS,” the committee wrote in a guideline document, “Adverse Events Associated with ERCP.”
“For endoscopists to accurately consider the clinical appropriateness of ERCP, it is important for them to have a thorough understanding of available alternatives and of the potential adverse events associated with the procedure. In addition, they must understand and attempt to follow maneuvers that reduce the risk of adverse events. Early recognition and appropriate management of potential adverse events are critical to reducing morbidity and mortality associated with the procedure.”
The guideline is intended to help endoscopists provide care to patients, but it is not a rule and “should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment,” according to the ASGE Standards for Practice Committee. “Clinical decisions in any particular case involve a complex analysis of the patient’s condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines.”
The document is 44 pages (not including references) and includes background information and in-depth analysis, as well as quick-hit recommendations, such as the following:
 	We recommend that physicians who perform ERCP be facile with procedural techniques that reduce the risk of pancreatitis (i.e., wire-guided cannulation, prophylactic pancreatic duct stenting).
 	We recommend early precut sphincterotomy for difficult biliary cannulation when expertise is available.
 	We recommend pancreatic duct stenting to reduce the incidence and severity of post-ERCP pancreatitis (PEP) in high-risk individuals.
 	We recommend administration of rectal nonsteroidal anti-inflammatory drugs (NSAIDS) to reduce the incidence and severity of PEP in high-risk individuals without contraindication.
 	We suggest that rectal indomethacin may reduce the risk and severity of post-ERCP pancreatitis in average-risk individuals.
 	We suggest that there is insufficient evidence that a combination of rectal NSAIDs and pancreatic duct stenting is superior to either technique alone for prevention of post-ERCP pancreatitis in high-risk individuals.
 	We suggest periprocedural intravenous hydration with lactated ringers when feasible to decrease the risk of post-ERCP pancreatitis.
 	We recommend against the routine use of endoscopic papillary large balloon dilation (EPLBD) of an intact sphincter rather than endoscopic sphincterotomy with or without adjunct balloon sphincteroplasty to facilitate biliary stone extraction in patients without coagulopathy because of the increased risk of pancreatitis. If EPLBD alone is used, dilation more than 1 minute is recommended.
 	We recommend that sphincterotomy should be selectively performed in patients considered high risk for bleeding. Routine sphincterotomy should not be offered in high-risk individuals for bleeding when not absolutely indicated.
 	We recommend the use of a microprocessor-controlled generator with mixed current when sphincterotomy is being performed to reduce the risk of post-sphincterotomy bleeding.
 	We recommend that antibiotic prophylaxis be administered before ERCP in patients who have had liver transplantation or when there is a possibility of incomplete biliary drainage. Antibiotics that cover biliary flora such as enteric gram-negative organisms and enterococci should be used and continued after the procedure if biliary drainage is incomplete.
 	We recommend that facilities ensure strict compliance with current manufacturer protocols and U.S. Food and Drug Administration recommendations for duodenoscope reprocessing to limit duodenoscope-related transmission of infections.
 	We suggest that patients with suspected periampullary or instrument-related perforations from ERCP without evidence of peritonitis or systemic inflammatory response syndrome (SIRS) may be managed non-operatively.
 	We suggest that premedication is not necessary to prevent contrast media allergy during ERCP in patients with a prior history of food or intravenous contrast allergies.
To access these guidelines in full, visit www.asge.org.
 
 

### Had COVID-19 But Your Friend Didn’t? Why the Difference?
Investigators in the Department of Computational Biomedicine at Cedars-Sinai wanted to find out which factors influenced susceptibility to COVID-19 infection and disease severity the most. Was it genetics? Or was it home environment, meaning the germs circulating throughout your everyday life?
The findings, published in the peer-reviewed journal Nature Communications, suggest that more was in play than either factor alone.
“Our results suggest that initially, differences in shared home environment influenced who was infected with COVID-19 more than genetic differences,” said Katie LaRow Brown, MA, first author of the study and a PhD candidate at Columbia University who collaborated with Cedars-Sinai on this study. “Over time, however, the importance of these differences in shared home environment decreased (and the importance of genetics increased) eventually eclipsing shared home environment.”
COVID-19 has infected more than 340 million people in the U.S., underscoring the urgency in conducting therapeutic research and uncovering potential treatments. However, until this study, little was known about how an individual’s environment and genetic background impacted their experience with the virus.
Using electronic health records from New York-Presbyterian/Columbia University Irving Medical Center, investigators identified 12,764 patients who received conclusive results (either positive or negative) from a PCR test for COVID-19. These patients belonged to 5,676 families with an average of 2.5 family members who had a bout of COVID-19. The time frame studied was Feb. 21, 2020, to Oct. 24, 2021.
The investigators’ analysis found that at the start of the pandemic, genetics accounted for 33% of variation in susceptibility. By the second half of the research study, however, genetics accounted for 70% of variation in susceptibility.
When measuring patients’ severity of COVID-19, investigators also found that a patient’s genetics were more of a factor than their home environment. Disease severity was defined by length of hospital stay. Genetics explained 41% of variation while shared environment explained 33%.
“We were especially surprised by the percentages of susceptibility,” said Nicholas Tatonetti, PhD, senior and corresponding author of the study, vice chair of Operations in the Department of Computational Biomedicine and an associate director of Computational Oncology at Cedars-Sinai Cancer. “Since this is an infectious disease, we assumed that home environment differences would explain most variation for the entirety of the study.”
While Tatonetti says his team of investigators cannot know for certain, they suspect that over time, discrepancies between people’s home environments changed in important ways.
“This work also suggests that the specific genetic factors influencing susceptibility and severity have not been fully identified,” said Tatonetti. “This is very important in terms of directing resources and defining future research goals.”
Jason Moore, PhD, chair of the Department of Computational Biomedicine and a professor of Medicine, said the study provides critical information and insights for future pandemics.
“The age-old debate of what matters most—genetics or your environment—continues through the work of this important study,” said Moore.

### The Endoscope Drying Process: Is it Time to Standardize?
By Kerry Dolan
Endoscope reprocessing is usually focused on achieving a sufficient and effective cleaning and disinfection process. However, recent studies have emerged highlighting the current pitfalls with endoscope drying and storage methods—showing worrying results. The endoscope drying process should be just as vital a component in reprocessing as cleaning and disinfection, but the current guidelines for endoscope drying are inconsistent and confusing for decontamination staff, and methods can vary widely between facilities.
Drying is a critical step in infection prevention, as any residual moisture left inside the endoscope channels can encourage biofilm formation. Endoscopes are saturated after reprocessing, and if there is any remaining moisture within the scope or the internal channels, this can lead to microbial growth.
Any imperfection in the endoscope cleaning process—inadequate cleaning and disinfection, insufficient drying, or inadequate storage—could result in post-endoscopic infections for the patient. However, the risk can be significantly reduced by any process used to dry the endoscope channels and by controlling storage conditions.
The significance of endoscope drying was identified in 1982, in a study by Gerding et al.[1] which showed that 31% of stored endoscopes were contaminated with bacteria. The study led to the introduction of forced-air drying to endoscope storage, which reduced the contamination rate to 5%. This, and several other studies that have followed, have all shown the importance of endoscope drying to manage microorganism escalation during storage.
Manual vs. Automated Drying
Flexible endoscopes can be dried in two ways: by manually drying the endoscope with lint-free cloths, and the channels with filtered, pressurized air for an extended period, after high-level disinfection and before storing in a conventional endoscope storage cabinet; or by placing the reprocessed endoscopes into a designated drying cabinet.[2] Standard storage cabinets are not automated and do not provide direct airflow through the endoscope's internal channels. Dedicated drying cabinets supply medical-grade compressed airflow through the endoscope channels and over external surfaces. Studies have shown that this process can vary across healthcare facilities and are always dependent on the human factor.[3]
Manual drying supported by medical compressed air is the straightforward method adopted by many facilities. A study in 2018 by Thaker[4] demonstrated that endoscope channels can be dried sufficiently using medical compressed air. Guidelines in the U.S. recommend a 10-minute drying cycle,[5] however, this is highly dependent on the human factor, which becomes particularly impractical when healthcare staff are under strict time restraints.
Automated drying cabinets are designed to dry the entire scope, the channels, and the outside[6] using a continuous flow of pressurized, filtered air through the scope channels. This ensures a standardized and validated drying and storage process in a closed environment. Drying can take between 90 minutes and several hours, depending on the type of endoscope. The efficiency of these cabinets has been demonstrated in several clinical and non-clinical studies.[7],[8],[9]
The latest technology has seen the birth of new drying-cabinet options, which have built-in artificial intelligence and safety aspects to ensure traceability and scope security, along with the more traditional channel drying features.
However, the endoscope-drying process is yet to be standardized in healthcare settings, meaning that while some facilities may acquire a designated drying and storage area with automated drying cabinets, other hospitals may only have provision for a standard storage cabinet available to them.
The guidelines in the UK, Europe, and the United States all facilitate endoscope drying, however, recommendations can differ between institutions. The use of alcohol flush is advocated by some for its antimicrobial activity and to promote drying, whereas other organizations do not endorse alcohol flushes due to concerns that the fixative effects of alcohol could encourage pathogens to be retained within endoscopes.[10],[11],[12],[13]
The manufacturer’s instruction manuals can also be vague, with some stating simply to “dry the channels” without providing specific details about which type of air, how to apply it, and the exact time required for sufficient drying.
Evidence is Key to Drying Time
In a study by Ofstead et al. in 2018, the drying methods of three different hospitals were evaluated. In Hospital A, endoscopes were reprocessed, and then placed directly into a cabinet to drip-dry. The technician would manually apply the air purge using a syringe. It was observed that the scopes were not hanging in a fully vertical position.
In Hospital B, endoscopes were wiped with towels then flushed with alcohol and air purged immediately after reprocessing, however, the towels they used were reused throughout the day before laundering. Endoscopes were then carried by hand and placed in the storage cabinet. It was noted that the cabinet had the facility for HEPA air filtration, but the fans were unplugged.
In Hospital C, scopes were wiped with single-use, lint-free towels, then at a designated drying station endoscopes were given air purge and alcohol flush and connected to pressure-regulated air for 10 minutes based on a study the hospital had conducted.
To obtain results, a borescope was used and test papers to identify any residual moisture in the scopes left to hang for 24 hours. The results showed that using the drip-dry method, 83% of the scopes had residual moisture, but in the facility that dried the scopes for 10 minutes, only 5% of the endoscopes that had residual moisture. The study concluded that 10 minutes of pressure-regulated forced air was most effective for drying endoscopes.[14]
When the droplets in the endoscopes were tested, they showed significant microbial growth, however it is important to note that these results could also be due to insufficient reprocessing methods, use of insoluble products or waterborne pathogens.[15]
A further study by Bakarat et al. inspected moisture residues retained in scopes after manual and automated drying processes. The results showed that no fluid retention was observed after 10 minutes of automated drying. The study evaluated five different scopes and tested manual and automated drying methods for 5 and 10 minutes to obtain these findings.[16]
To establish the efficacy of automated drying of endoscopes in cabinets, in a further study, three different types of endoscopes were evaluated. A colonoscope (Olympus), duodenoscope (Fujinon) and an enteroscope (Pentax) were all artificially contaminated before the testing process and changes were observed to the residual internal contamination level when stored inside and outside of the drying cabinet for 12-, 24-, 48- and 72-hour periods.
When compared, the findings showed that when scopes were stored inside the drying cabinet, microbial contamination levels on the scopes were lower than the number of bacteria initially introduced and could decrease considerably thereafter. [17] For endoscopes stored outside the drying and storage cabinet, microbial numbers were stable or increased.
Safe Storage, but for How Long?
A cabinet that keeps endoscopes secure and avoids contact with contaminated surfaces, but does not dry the scopes, is referred to as a storage cabinet. If an endoscope is not to be used immediately on the next patient, the scope and its components must be dried and stored away from contamination.[18]
Appropriate storage is key to maintaining endoscopes’ functionality. Endoscopes should hang freely in a closed, well-ventilated storage cabinet to avoid damage and facilitate drying. Cabinets should have a HEPA filter and provide safe storage for endoscope accessories.
However, there is insufficient data to provide a maximum duration for the use of appropriately cleaned, reprocessed, dried, and stored flexible endoscopes. According to an article reviewed and approved by the ASGE by Day et al., endoscopy units should evaluate the available literature, perform an assessment as to the benefits and risks around the optimal storage time for endoscopes, and develop a policy and system specific to their facility on endoscope storage time.[19]
According to the same report, they suggest that some users may choose a combination of both cabinet types; this is dependent on their facility. Some hospitals may have controlled environment storage cabinets for daily-use endoscopes, and separate storage cabinets for the endoscopes only in occasional use and where reprocessing before use is cost-effective.[20]
Current recommendations recommend that flexible endoscopes should be stored in closed, ventilated cabinets that have been designed for vertical storage, or those with sufficient height, width, and depth to allow the scopes to hang freely without coiling.[21]
AORN recommends that if a drying cabinet is not available, flexible scopes may be stored in a closed cabinet with the ability for HEPA filtered air that can provide a positive pressure and allow air circulation around the endoscopes.[22] AORN also recommends that flexible endoscopes and endoscope accessories be stored in a manner that minimizes contamination and protects the device or item from damage.
Damage Control
Drying and storage cabinets do not protect the distal end from damage, and care should be taken when placing scopes in the cabinet and on removal, because damage can occur if endoscopes are allowed to come into contact with each other. In addition, the insertion tube and light guide can clash with hard surfaces while in the cabinet,[23] which can damage the delicate optics of the scope.
Some scopes are too long to fit into the cabinet and can be damaged when the distal end hits the floor. Using a distal tip protector that is suitable for use in a drying cabinet can reduce the risk of damage. Several tip protection options are available in the market, but when choosing it is important to consider that a tip protector made of material that can retain moisture, like a sponge, can create an environment favourable for microbial growth.
Distal tip protectors should not cover the opening of the tip and should be single-use, unless otherwise specified in the manufacturer’s written IFU.[24] A preferred choice should allow maximum air flow while in the storage cabinet, such as the ProTech distal tip protector.
Should Drying Cabinets be Mandatory?
Current guidelines do not enforce drying or storage cabinets within healthcare facilities, but they are recommended.[25] Endoscopy units are left to decide their own methods for endoscope drying, which is more often determined by departmental budget and capacity.
Drying and storage cabinets are large pieces of equipment that not only require plenty of space, but also a large chunk of departmental funding. According to an article in the Hospital Times in 2019, the purchase cost of an EN 16442-compliant drying and/or storage cabinet was $25,000–$40,000. In addition, the running and maintenance costs can range from $4,300–$5,000 per cabinet, per year.[26]
Despite evidence indicating that endoscope drying is a fundamental step in the reprocessing cycle, a paper by Thacker et al. identified that of 249 U.S. institutions surveyed concerning duodenoscope processing practices, 52.2% did not use forced-air drying after reprocessing.[27]
With so many regulations applied for reprocessing endoscopes, it seems incorrect that there is not a requisite towards a standardized drying process. If endoscope drying is an essential factor in reprocessing, why isn’t sufficient funding available to ensure that all facilities have identical drying equipment and processes?
Conclusion and Future Development
The use of drying and storage cabinets for endoscopes should be advocated by all healthcare facilities to reduce microbial contamination after reprocessing. Drying cabinets are not designed to improve reprocessing but should be used in conjunction with current reprocessing methods to maintain endoscope cleanliness and viability for the next patient.
However, with the inconsistency of current guidelines between facilities, a serious issue needs to be addressed. Institutions should be looking to create a standardized process for endoscopes to ensure they are subject to the same drying and storage conditions in all healthcare settings to ensure safe, reprocessed, patient-ready endoscopes.
Additionally, an improved testing method for reprocessed scopes should be developed to ensure that endoscopes are not left with residual moisture in the channels. It is the responsibility of all societies to create consistent guidelines to make this aspect of the reprocessing cycle standardized, in order to ensure the safety of patients everywhere.
Kerry Dolan has had a long career in freelance writing and is currently head of marketing for Meditech Endoscopy Ltd., a global product development company. Her marketing expertise focuses on creating innovative marketing strategies, content creation and managing the company website and social media accounts. Dolan has a special interest in creating awareness about the challenges that endoscopy staffers experience, and to provide solutions that combine industry and nursing staff working together for better patient outcomes.
 
References
[1] Cleaning & disinfection of fiberoptic endoscopes evaluation of glutaraldehyde exposure time and forced air drying. D.N. Gerding et al. Gastroenterology, 1982.
https://www.sciencedirect.com/science/article/pii/S0016508582801972
[2] Hung Out to Dry: The Importance of Endoscope Channel Drying Prior to Storage By Melinda Benedict, MS, CIC, CFER Manager, Infection Control Program Olympus Corporation of the Americas
Melinda Benedict
[3] Residual moisture and waterborne pathogens inside flexible endoscopes: Evidence from a multisite study of endoscope drying effectiveness. Ofstead, C, Heymann, O.L, Quick, M.R, MPH, Eiland, E. RN, MS, Wetzler, H.P. MD, MSPH. American journal of Infection control, Vol 46, issue 6, June 2018, P689-696.
[4] Thaker A M, Kim S et al. Inspection of endoscope instrument channels after reprocessing using a prototype borescope. Gastrointestinal Endoscopy, 2018: 88; 612-619.
[5] Day L W, Muthusamy V R, Collins J et al. Multisociety guideline on reprocessing flexible GI endoscopes and accessories. Gastrointestinal Endoscopy, 2021: 93; 11-33.
[6] Endoscope drying and its pitfalls. Kovaleva,J. Journal of Hospital Infection, July 2017. https://pubmed.ncbi.nlm.nih.gov/28729139/
[7] Pineau L, Villard E, Duc D L et al. Endoscope drying/storage cabinet: interest and efficacy. J Hosp Infect. 2008;68:59–65.
[8] Grandval P, Hautefeuille G, Marchetti B et al. Evaluation of a storage cabinet for heat-sensitive endoscopes in a clinical setting. J Hosp Infect. 2013;84:71–76. doi: 10.1016/j.jhin.2013.01.013
[9] Perumpail R B, Marya N B, McGinty B L et al. Endoscope reprocessing: Comparison of drying effectiveness and microbial levels with an automated drying and storage cabinet with forced filtered air and a standard storage cabinet. Am J Infect Control. 2019;47:1083–1089. doi: 10.1016/j.ajic.2019.02.016.
[10] Health Technical Memorandum 01-06: Decontamination of flexible endoscopes. Part C. Operational management. 3.38 (9) Drying.
[11] Reprocessing of flexible endocopes and endoscopic accessories used in gastrointestinal endoscopy: Position statement of the European Society of gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology Nurses & Associates (ESGENA) Update 2018. (6.7)
[12] ANSI / AAMI ST91:2015
[13] British society of Gastroenterology Guidance on Decontamination of Equipment for Gastrointestinal Endoscopy (10)
[14] Residual moisture and waterborne pathogens inside flexible endoscopes: Evidence from a multisite study of endoscope drying effectiveness. Ofstead C.L, Heymann O.L, Quick M.R, Eiland J.E, Wetzler H.P. AJIC June 2018:46(6):689-696
[15] Residual moisture and waterborne pathogens inside flexible endoscopes: Evidence from a multisite study of endoscope drying effectiveness. Ofstead C.L, Heymann O.L, Quick M.R, Eiland J.E, Wetzler H.P. AJIC June 2018:46(6):689-696
[16] Comparison of automated and manual drying in the elimination of residual endoscope working channel fluid after reprocessing. Monique T Barakat, MD, PhD, Robert J. Huang, MD, and Subhas Banerjee, MD. Published in Gastrointestinal Endoscopy 2019, issue 89.
[17] Endoscope drying / storage cabinet: interest and efficacy. Pineau, L., Villard, E., Duc, D, L., Marchetti, B. Journal of Hospital Infection, Jan 2008. https://pubmed.ncbi.nlm.nih.gov/18055064/
[18] Beilenhoff U, Biering H, Blum R et al. Reprocessing of flexible endoscopes and endoscopic accessories used in gastrointestinal endoscopy: Position Statement of the European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology Nurses and Associates (ESGENA) – Update 2018. Endoscopy. 2018;50:1205–1234. doi: 10.1055/a-0759-1629.
[19] Multisociety guideline on reprocessing flexible GI endoscopes & accessories. Day et al. Gastrointestinal Endoscopy, November 2020.
[20] Multisociety guideline on reprocessing flexible GI endoscopes & accessories. Day et al. Gastrointestinal Endoscopy, November 2020.
[21]Drying and storing of flexible endoscopes: An area of growing concern. Behm, T. MSN, RN, CIC, Robinson, N. PhD. AAMI, May / june 2020. https://www.aami.org/docs/default-source/bi-t/bit/drying-storing-endoscopes---bit-may-june-2020.pdf
[22] Guideline summary: Processing flexible endoscopes. AORN journal, September 2016, Vol 104, No. 3. (XI)
[23] Which drying cabinet is right for your endoscopes? Dhalin, D. The Inside Tract. https://theinsidetract.sgna.org/Article/ArtMID/385/ArticleID/235/Sponsored-Which-Drying-Cabinet-Is-Right-for-Your-Endoscopes
[24] AAMI ST91 2021, page 68
[25] The British thoracic Society. Du Rand IA, Blaikley J, Booton R, et al. British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults. Thorax 2013;68:i1-i44.
[26] Resolving endoscope storage issues and saving money. Hospital Times, 2019.
[27] Thacker A.M, Muthusamy V.R, Sedarat A et al. Duodenoscope Reprocessing Practice patterns in US Endoscopy Centres: A survey study. Gastrointestinal Endoscopy, 2018 – 88(2): 316-22.
 
 
Sidebar
What Harm Can a Little Moisture Do?
Why Thorough Drying of Flexible Endoscopes is So Important
By Nancy Chobin, RN, AAS, ACSP, CSPM, CFER
Water is critical for the survival of life on earth. According to Weymiller, “Around 60 percent of our body is made up of water and we can only live three to five days without fluids.” Our bodies use water to flush waste, regulate temperature, digest our food properly and transport nutrients.
Moisture can encourage the growth of certain microorganisms, such as Pseudomonas aeruginosa, a relatively common bacteria found in soil and water, as well as other environmental locations. Of the various strains of Pseudomonas, the one that most often causes infections in humans is Pseudomonas aeruginosa.
Standards and Guidelines
According to the Centers for Disease Control and Prevention, Pseudomonas aeruginosa “can cause infections in the blood, lungs (pneumonia), or other parts of the body after surgery. These bacteria are constantly finding new ways to avoid the effects of the antibiotics used to treat the infections they cause. Antibiotic resistance occurs when the germs no longer respond to the antibiotics designed to kill them. If they develop resistance to several types of antibiotics, these germs can become multidrug-resistant.” The Multisociety Guideline on Reprocessing GI Endoscopes and Accessories states that endoscopes “should undergo drying after the completion of all reprocessing steps as described in the endoscope manufacturers’ IFU.”
The Association for the Advancement of Medical Instrumentation (AAMI) recommends that an endoscope and its components “should be dried after completion of the cleaning and disinfection process. Flexible endoscopes with channels should be dried for a minimum of 10 minutes with pressure-regulated forced instrument air or a minimum of HEPA-filtered air (Ofstead, 2018 [242]; Barakat, 2018 [79]”.
SGNA agrees. “Drying is a critical element in reprocessing. Moisture allows microorganisms to survive and multiply; therefore, all channels and the surface of the endoscope must be thoroughly dried before storage. Outbreaks of Pseudomonas aeruginosa, Acinetobacter spp., carbapenemase-producing K pneumoniae, and other pathogens have been traced to inadequately dried endoscopes (Alfa, 2013; Carbonne et al., 2010; Kovaleva et al., 2013).”
The Association of peri-Operative Registered Nurses (AORN) offers similar guidelines. “Dry the exterior surfaces of the endoscope with a soft, lint-free cloth or sponge. Dry the endoscope channels by purging with instrument air of using a mechanical processor drying system. Dry removeable parts and endoscope accessories.”
A 2018 study looked at endoscope reprocessing at three hospitals. The authors wrote, “Fluid was detected in 22 of 45 (49%) endoscopes. Prevalence of moisture varied significantly by site (5%; 83%; 85%; P < .001). High adenosine triphosphate levels were found in 22% of endoscopes, and microbial growth was detected in 71% of endoscopes. Stenotrophomonas maltophilia, Citrobacter freundii, and Lecanicillium lecanii/Verticillium dahliae were found. Retained fluid was associated with significantly higher adenosine triphosphate (ATP) levels (P < .01). Reprocessing and drying practices conformed with guidelines at 1 site and were substandard at 2 sites. Damaged endoscopes were in use at all sites.” This study demonstrated the magnitude of the problem and why we need to focus on the critical drying part of reprocessing flexible endoscopes.
What Should You Do?
When there are varying recommendations, it is important to determine which guidelines your facility will follow. Then develop policies and procedures based upon those guidelines and monitor for staff compliance.
Drying can be accomplished manually using either instrument air or HEPA filtered air. Instrument air is defined as “a medical gas that falls under the general requirements for medical gases as defined by the National Fire Protection Association (NFPA) 99: Health Care Facilities Code, is not respired, is compliant with the ANSI/ISA S-7.0.01, Quality Standard for Instrument Air, and is filtered to 0.01 micron, free of liquids and hydrocarbon vapors, and dry to a dew point of -40º F (-40º C).” Instrument air may be supplied from cylinders, bulk containers and/or medical air compressors.
The definition of a medical air compressor (per NFPA) is a compressor that is designed to exclude oil from the air stream and compression chamber and that does not, under normal operating conditions or any single fault, add toxic or flammable contaminants to the compressed air.
Manual drying can be achieved by blowing instrument air through all endoscope channels for a specified period of time and at the recommended pressure. There are insufficient data regarding the effectiveness of using a 70% to 80% ethyl- or isopropyl-alcohol flush after air drying. If it is facility policy to use an alcohol flush, personnel should follow the endoscope manufacturer’s IFU on the volume of alcohol and method to be used for each endoscope lumen and then remove any remaining alcohol with instrument air (or as otherwise recommended by the endoscope manufacturer). The manufacturer's written IFU should also be consulted regarding the appropriate air pressure in relation to channel size. Syringes should not be used to dry channels. All removable endoscope parts should also be dried (ANSI.AAMI ST-91).
Proper storage of endoscopes is paramount for maintaining their functionality and ensuring patient safety. Endoscope storage cabinet guidelines should be well-ventilated to prevent moisture buildup and subsequent bacterial growth. Each endoscope should be stored separately to prevent cross-contamination, and thorough drying before storage is essential. Endoscope storage cabinet guidelines with built-in drying systems are preferable. Security measures should be in place to prevent unauthorized access, and regular maintenance and inspections are necessary to ensure cabinets remain in optimal condition. Adhering to these guidelines is crucial for healthcare facilities to safeguard their endoscopes and uphold high standards of patient care.
If the endoscope is not completely dry after 10 minutes (or the time recommended by the endoscope manufacturer), continue to dry the scope. Verification of complete drying can be difficult since there are small channels on the scope. There are various tests on the market to determine dryness, but these tests might not be definitive. Some facilities use a borescope to view the internal channels of the endoscope for cleanliness, damage, and any evidence of moisture. Every effort should be made to ensure the endoscope is completely dry.
A second method of drying is to place the HLD and rinsed endoscope into a drying cabinet. A drying cabinet is not the same as a conventional storage cabinet. Conventional cabinets have HEPA-filtered air that is circulated throughout the cabinet and around the surfaces of the endoscopes. However, drying cabinets differ because they have adapters that provide HEPA-filtered or instrument air not only around the outside of the scopes, but also inside the channels of the scopes. Drying cabinets dry the endoscope, whereas conventional cabinets do not. So if your facility has a drying cabinet, manual drying is not needed (ANSI/AAMI ST-91 (2021).
If your facility does not have drying cabinets, then manual drying is needed. Storage cabinets without HEPA-filtered air should not be used. It is essential that the drying cabinet manufacturer’s IFUs are followed exactly as stated and that staff is trained in the use of the cabinet, especially how to connect the adapters to the endoscope, clean the cabinet, and perform any recommended maintenance.
The endoscope manufacturer’s written IFUs for the recommended procedure for drying their specific models of endoscopes, including the amount of pressure to be used, should be followed at all times. It is important to monitor staff compliance with drying procedures and to ensure that every effort has been made to produce a dry endoscope to prevent recontamination of the scope while in storage.
Nancy Chobin, RN, AAS, ACSP, CSPM, CFER, is the president and CEO of Sterile Processing University, LLC, of Lebanon, New Jersey. Her company was founded in 1996 and provides SPD and GI consultations, competency assessments, design of sterile processing areas (in hospitals, surgery centers and endoscopy processing areas), on-site training, and online training courses for ambulatory surgery, SPD and endoscopy processing personnel. 
 
 
 

### Crohn’s & Colitis Foundation Launches New IBD Clinical Trials Community to Educate and Support Clinical Trial Participation
Clinical trial recruitment is a challenging step toward FDA approval of new treatments for patients across all disease states; this is especially true for inflammatory bowel diseases (IBD), including those impacting the prognosis of Crohn’s disease. The Crohn’s & Colitis Foundation (the Foundation) launched today a dedicated Clinical Trials Community (the Community) for IBD. The Community is designed to educate patients, caregivers, and healthcare providers about the clinical trial process, its value, and how to address barriers that exist in enrollment.
“These recruitment difficulties cause delays in attaining the critical data needed to move the drug development process forward,” said Michael Osso, President and CEO of the Crohn’s & Colitis Foundation. “Our Clinical Trials Community will provide education and resources to help overcome these challenges and accelerate treatment options toward approval.”
The Foundation conducted research including a literature review, landscape analysis, and focus groups among the IBD patient population, which confirmed that barriers to clinical trial participation include insufficient awareness of available clinical trials and lack of understanding of the process. This initiative is particularly significant for individuals concerned about the prognosis of Crohn’s disease, as clinical trials play a crucial role in advancing new treatments and improving long-term outcomes.
“We know through our research that patients would be willing to participate in clinical trials if they were able to learn more about the purpose and importance of clinical trial research,” Osso said. “With a dedicated, singular resource, we are empowering patients to make decisions that are right for them, cultivating a culture of citizen scientists and creating opportunities for patients to support research that affects the whole IBD community.”
The IBD Clinical Trials Community has been created to educate about and raise awareness of clinical trials among patients and caregivers, provide resources to identify and participate in relevant clinical trials, and support and improve patient and provider communication about engaging in clinical trials. This initiative is particularly important for those concerned about the prognosis of Crohn’s disease, as clinical trials play a crucial role in developing new treatment options.
The Community will be implemented using a phased approach beginning with the launch of the new website, including an educational video series, patient stories, an IBD clinical trial finder, and research updates. Over the remainder of 2017, the Crohn’s & Colitis Foundation will roll out a clinical trial ambassador program, clinical trial communications, and educational tools for Crohn’s & Colitis Foundation programs and events across the country. These efforts aim to enhance awareness and accessibility of clinical trials, ultimately contributing to improved treatment outcomes for individuals affected by Crohn’s disease and ulcerative colitis.
The Crohn’s & Colitis Foundation’s Clinical Trial Community is made possible by support from AbbVie, Celgene Corporation, Genentech, Inc., and Takeda Pharmaceuticals U.S.A., Inc.
About the Crohn’s & Colitis Foundation 
The Crohn's & Colitis Foundation is the largest non-profit, voluntary health organization dedicated to finding cures for inflammatory bowel diseases (IBD). The Foundation’s mission is to cure Crohn's disease and ulcerative colitis, and to improve the quality of life of children and adults who suffer from these diseases. The Foundation works to fulfill its mission by funding research; providing educational resources for patients and their families, medical professionals, and the public; and furnishing supportive services for those afflicted with IBD. For more information visit http://www.crohnscolitisfoundation.org, call 888-694-8872, or email info@crohnscolitisfoundation.org.

### Keep Warm with the Heated Vest
Fraser, MI, July 15th 2016-Healthmark Industries announces the addition of The Heating Vest to its Personal Protection Equipment (PPE) accessory line.
Keep warm in cool environments with our reusable heated vest that emits comfortable levels of warmth for the wearer's torso to keep cozy in cool ambient conditions. Fashioned with a soft-shell barrier fleece fabric, the Heating Vest features zippered front pockets with adjustable elastic cord at the bottom and zipper closure provides comfort and mobility.
The Heating Vest comes equipped with a controller that has three temperature settings for selecting the desired amount of heat, removable heating elements for easy cleaning and a LI-Ion battery that pairs with the supplied charger.
Visit www.hmark.com or call 800-521-6224 for more information.

### Healthmark Offers Self-Seal CLEAN Bag
Healthmark Industries has announced the addition of the Self-Seal CLEAN Bag to its Bags & Dust Covers product line.
Storing reprocessed medical devices appropriately is crucial to avoid environmental contamination. The new Self-Seal CLEAN Bag has been created to keep items covered after cleaning, disinfection or sterilization. The 6x9 inch tamper evident self-seal bags are clear and printed with “CLEAN” in green lettering for easy identification of contents and “clean” status. They are Ideal for transportation and storage.
Visit www.hmark.com or call 800-521-6224 for more information.

### Healthmark Offers the Clean Label
Healthmark Industries has announced the addition of the Clean Label to its Labeling line. Manufactured to convey key information to healthcare professionals, the clean label is intended to conceal and cover the bio symbol on SST systems when transporting clean medical instruments.
The Clean Label provides effective communication among healthcare professionals in various departments. The label is a 4x4 inch design with a removable adhesive backing that has a green colored background and “CLEAN” in white text.
Visit www.hmark.com or call 800-521-6224 for more information.

### Takeda Launches Wearable Digital Technology Pilot Program to Support Patients and Healthcare Providers with Inflammatory Bowel Disease Management
Takeda Pharmaceuticals U.S.A., Inc. ("Takeda"), announced the launch of a pilot digital technology program to support patients and physicians with the management of inflammatory bowel disease (IBD). Digital approaches are being used to develop solutions across many sectors of healthcare, with cutting-edge technology elevating and transforming disease diagnostics, measurement, treatment and more. This program, iBData, is designed to intersect healthcare and digital technologies. In partnership with Texas Digestive Disease Consultants (TDDC) and Vanderbilt University Medical Center (VUMC), this pilot program will allow patients with IBD to track their symptoms and lifestyle factors with wearable watch technology. The data will be collected and translated into reports intended to help enhance patient-physician interaction with the goal of improved care.
"The wearable aspect of the technology being used for iBData provides an opportunity to investigate how we as physicians monitor, assess and treat our patients," said Tim Ritter, MD, Medical Director, Luminal Research, TDDC.
"We are very excited about this project and its potential for both patients and physicians," said Dawn M. Beaulieu, MD, assistant professor of medicine, Division of Gastroenterology, Hepatology & Nutrition, VUMC. "Giving patients the power to capture robust, real-time monitoring of their symptoms will help us as physicians to create a personalized treatment plan. Our hope is that this will ultimately result in better disease control and improved IBD care."
The initial rollout of the program will involve approximately 100 patients. iBData aims to improve conversations between patients and physicians in the exam room and between visits, fostering productive and ongoing dialogues, and improve the understanding of individual patients' conditions. This includes analyzing symptoms, triggers and aggravating factors in an effort to expand the ability to treat individuals and potentially improve outcomes.
"At Takeda, part of what fuels our ongoing dedication to advanced research in the field of gastroenterology is our deep understanding of the challenges that dictate unique needs for both patients and physicians managing IBD," explained Stephanie Brown, vice president, head, Specialty Business Unit, Takeda. "iBData leverages the remarkable capabilities available today when wearable technologies and medicine converge, in an effort to help overcome these challenges. This innovative pilot program will explore new ways to transform care by generating novel insights into the patient experience that physicians can directly utilize."
About Ulcerative Colitis and Crohn's Disease
Ulcerative colitis (UC) and Crohn's disease (CD) are marked by inflammation in the lining of the gastrointestinal tract. UC impacts the large intestine only, which includes the colon and the rectum, while CD can impact any part of the digestive tract, and predominantly affects the ileum. There is no known cause for UC and CD, although many researchers believe that the interaction between genes, the body's immune system, and environmental factors may play a role.
About Takeda Pharmaceuticals U.S.A., Inc.
Takeda is a research-based global company with its main focus on pharmaceuticals. As the largest pharmaceutical company in Japan and one of the global leaders of the industry, Takeda is committed to strive towards better health for people worldwide through leading innovation in medicine.
The company has a commercial presence covering around 70 countries, with particular strength in Asia, North America, Europe and fast-growing emerging markets including Latin America, Russia-CIS and China. Areas of R&D focus include central nervous system, cardiovascular and metabolic, gastroenterology, oncology, and vaccines.
Takeda Pharmaceuticals U.S.A., Inc. is located in Deerfield, Ill., and is the U.S. marketing and sales organization of Takeda Pharmaceutical Company Limited.
Additional information about Takeda is available through its corporate website, www.takeda.com, and additional information about Takeda Pharmaceuticals U.S.A., Inc. is available through its website, www.takeda.us.

### Washable Keyboard and Mouse
Healthmark Industries has introduced the Washable Keyboard and Mouse to its ProSysTM Instrument Care product line. Manufactured from silicone, the waterproof white keyboard and mouse are intended for use in the decontamination area. Both items are designed with a USB connection and an enclosed silicone housing to resist frequent cleaning.
The 375 x 150 x 11 mm Washable Keyboard comes equipped with 106 keys including a numeric pad and can be cleaned with hospital grade cleaning agents and wiped down with hospital grade disinfectants. The 116.0 x 62.0 x 38.6 mm Washable Mouse is assembled with integrated scroll keys, laser detection and can be cleaned with hospital grade cleaning agents and wiped down with hospital grade disinfectants. The Washable Keyboard and Mouse are available for purchase together or separately.
Visit www.hmark.com or call 800-521-6224 for more information.

### Healthmark Industries Offers Gown with Thumb Loop
Healthmark Industries has announced the addition of Gown with Thumb Loop to its Personal Protection Equipment (PPE) line. 
OSHA’s Bloodborne Pathogens Standard (29 CFR 1910.1030) requires employers to protect workers who are occupationally exposed to blood and other potentially infectious materials, which is why we’ve developed a single-use full frontal barrier gown for healthcare professionals.
The Gown features lightweight latex-free blue recyclable polyolefin that is manufactured in the USA. It is 4 mil thick that is 50 Inches in length and has full-length sleeves with a thumb loop cuff style, along with a tie back closure type to secure the garment.
Visit www.hmark.com or call 800-521-6224 for more information.

### New study finds that inflammatory proteins in the colon increase incrementally with weight
Studies in mice have demonstrated that obesity-induced inflammation contributes to the risk of colorectal cancer, but evidence in humans has been scarce. A new study shows that two inflammatory proteins in the colon increase in parallel with increasing weight in humans. An incremental rise in these pro-inflammatory proteins (called cytokines) was observed along the entire spectrum of subjects' weights, which extended from lean to obese individuals. In participants with obesity, there was evidence that two pre-cancerous cellular pathways known to be triggered by these cytokines were also activated.
The study, while modest in size, provides new evidence that obesity promotes cancer through inflammation. Secondary findings suggest that NSAIDS lower the levels of pro-inflammatory proteins in the colon, regardless of a person's weight. The study is published online in advance of print in Cancer Epidemiology, Biomarkers & Prevention.
Led by Joel B. Mason, M.D., a gastroenterologist who studies nutrition and cancer prevention at the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University (HNRCA), the study included 42 Caucasian participants. Sixteen research participants were lean, with a BMI between 18.1 and 24.9, while 26 participants with obesity had a BMI ranging from 30.0 to 45.7. The participants were between the ages of 45 and 70 years of age and were undergoing routine screening colonoscopies at Tufts Medical Center.
Using blood samples and colonic biopsies, the researchers determined that the concentrations of two major cytokines rose in parallel with BMI. Cytokines are proteins that mediate and regulate immunity and inflammation, among other things. In addition to evidence that they can promote cancer risk in certain tissues, pro-inflammatory cytokines have been identified as actors in insulin resistance and diabetes, as well as inflammatory disorders such as arthritis.
In addition to the work analyzing cytokines, the research team studied differences in the mucosal transcriptome between the two sets of research participants, finding changes indicative of activation in two gene expression networks that are pivotal in the development of colon cancer in the participants with obesity.
"Our results establish, for the first time, that concentrations in the colon of two major cytokines increase in concert with increasing BMI in humans. The increased concentrations are accompanied by changes in gene activation within the lining of the colon that are pro-cancerous in nature," said senior author Joel B. Mason, MD, director of the Vitamins and Carcinogenesis Laboratory at the HNRCA.
In an effort to identify potential confounding factors, the research team determined that thirteen of the 42 study participants were also regular users of NSAIDs, such as aspirin and ibuprofen. The research team discovered that participants who took NSAIDs at least once per week, compared to those who did not, had lower levels of pro-inflammatory proteins in the colon. This pattern was consistent across the two BMI groups.
"Observational and clinical trials show aspirin can reduce the risk of colon cancer, but it continues to be controversial because of the risk of serious gastrointestinal bleeding. NSAIDs are probably working through multiple avenues, one of which is cytokines. Our observation underscores prior work that has suggested that some NSAIDs reduce the risk of colon cancer, presumed to occur through a reduction in colonic inflammation. Their use, however, has to be weighed against the potential adverse effects," said Mason.
The authors noted that the modest study size and the Caucasian population are limitations of the study, writing "given the cross-sectional nature of this study, the results cannot prove that the observed changes in the colonic transcriptome are due to the rise in cytokines...Observations from this study nevertheless underscore the potential contribution that the establishment of an inflammatory milieu in the colonic mucosa may play in explaining the enhanced risk of colon cancer due to obesity."
In the United States, colorectal cancer is the third most common cancer and the second leading cause of death among cancers that affect both men and women, according to the CDC. The American Cancer Society reports that the overall lifetime risk of developing colorectal cancer is about 1 in 22 for men and 1 in 24 for women.
Source: TUFTS UNIVERSITY

### Healthmark Offers the Multi-Purpose Label!
Healthmark Industries has announced the addition of the Multi-Purpose Equipment Label to its Labeling line. It ensures proper labeling for medical equipment to communicate crucial information, addressing one of the many unique challenges healthcare facilities are tasked with daily.
The Multi-Purpose Equipment Label was developed as a way to ensure consistency and identify whether medical equipment is either clean, in-use or dirty. The 2” x 3” label has an easy to use pull tab style design with an adhesive backing that does not leave residue behind. The brightly colored label provides high visibility to healthcare professionals, allowing individuals to correctly communicate the status of equipment.
About Healthmark Industries Co., Inc. 
Since 1969, Healthmark Industries Company, Inc. has developed and marketed innovative solutions to aid healthcare facilities in their delivery of surgical instruments and other life-saving medical devices to patients. Healthmark Industries mission is to continue to innovate, continue to support and continue to serve the healthcare provider industry and support services that make it possible to deliver quality healthcare. Visit www.hmark.com for more information.

### NIH study finds probiotic Bacillus eliminates Staphylococcus bacteria
A new study from National Institutes of Health scientists and their Thai colleagues shows that a "good" bacterium commonly found in probiotic digestive supplements helps eliminate Staphylococcus aureus, a type of bacteria that can cause serious antibiotic-resistant infections. The researchers, led by scientists at NIH's National Institute of Allergy and Infectious Diseases (NIAID), unexpectedly found that Bacillus bacteria prevented S. aureus bacteria from growing in the gut and nose of healthy individuals. Then, using a mouse study model, they identified exactly how that happens. Researchers from Mahidol University and Rajamangala University of Technology in Thailand collaborated on the project.
"Probiotics frequently are recommended as dietary supplements to improve digestive health," said NIAID Director Anthony S. Fauci, M.D. "This is one of the first studies to describe precisely how they may work to provide health benefits. The possibility that oral Bacillus might be an effective alternative to antibiotic treatment for some conditions is scientifically intriguing and definitely worthy of further exploration."
Staphylococcus infections cause tens of thousands of deaths worldwide each year. Methicillin-resistant Staphylococcus aureus, or MRSA, is familiar to many people as a cause of serious disease. Less well known is that S. aureus often can live in the nose or gut without causing any harm. However, if the skin barrier is broken, or the immune system compromised, these colonizing bacteria can cause serious infections.
One strategy to prevent Staph infections is to eliminate S. aureus colonization. However, some decolonization strategies are controversial because they require considerable amounts of topical antibiotics and have limited success, partly because they target only the nose and bacteria quickly recolonized from the gut.
The scientists recruited 200 volunteers in rural Thailand for the study. This population, they speculated, would not be as affected by food sterilization or antibiotics as people in highly developed urban areas. The scientists first analyzed fecal samples from each of the study participants for bacteria correlated with the absence of S. aureus. They found 101 samples positive for Bacillus, primarily B. subtilis--the type found mixed with other bacteria in many probiotic products. Bacillus bacteria form spores that can survive harsh environments and commonly are ingested naturally with vegetables, allowing them to temporarily grow in the intestine. The scientists then sampled the same 200 people for S. aureus in the gut (25 positive) and nose (26 positive). Strikingly, they found no S. aureus in any of the samples where Bacillus were present.
In mouse studies, the scientists discovered an S. aureus sensing system that must function for the bacteria to grow in the gut. Intriguingly, all of the more than 100 Bacillus isolates they had recovered from the human feces efficiently inhibited that system.
Using chromatography and mass spectrometry techniques, the scientists identified fengycins, a specific class of lipopeptides--molecules that are part peptide and part lipid--as the specific Bacillus substance that inhibited the S. aureus sensing system. Additional tests showed that fengycins had the same effect on several different strains of S. aureus--including high-risk USA300 MRSA which causes most community-associated MRSA infections in the United States and is an increasingly common cause of healthcare-associated MRSA infections.
To further validate their findings, the scientists colonized the gut of mice with S. aureus and fed them B. subtilis spores to mimic probiotic intake. Probiotic Bacillus given every two days eliminated S. aureus in the guts of the mice. The same test using Bacillus where fengycin production had been removed had no effect, and S. aureus grew as expected.
The NIAID and Thai scientists next plan to test whether a probiotic product that contains only B. subtilis can eliminate S. aureus in people. They plan to enroll more Thai volunteers for the project. Michael Otto, Ph.D., the NIAID lead investigator, says, "Ultimately, we hope to determine if a simple probiotic regimen can be used to reduce MRSA infection rates in hospitals."
Source: NIH/NATIONAL INSTITUTE OF ALLERGY AND INFECTIOUS DISEASES

### Handheld Multi-Magnifier
Healthmark Industries has announced the addition of the Handheld Multi-Magnifier to their Optical Inspection product line.
This unique product features magnifications of 3x 10x, and 55x lenses, five LED lights for illumination and a light switch with four modes, conveniently built into one unit
Designed to comply with AAMI ST91 for enhanced visual inspection of flexible endoscopes, the Handheld Multi-Magnifier is a useful tool to perform detailed visual inspection of flexible endoscopes that allow the assessment of external surfaces. The metal coated unit is 115 x 40 x 10mm (4.5 x 1.5 x 0.4 inches) and includes three 1.5v batteries.  www.hmark.com

### Funding awarded to improve vaccine use and preventative health maintenance in IBD patients
The American College of Gastroenterology (ACG), the American Gastroenterological Association (AGA), and the Crohn’s & Colitis Foundation (Foundation), in partnership with Pfizer, Inc., have announced the results of a request for proposal (RFP) to address vaccine utilization, promote health maintenance, and increase preventive care services in patients with inflammatory bowel diseases (IBD).
“Applicants were encouraged to design programs or initiatives that explore or address gaps in vaccine utilization and/or communication amongst providers related to the RFP topic,” noted Francis A. Farraye, MD, MSc, FACG, AGAF, director of the Inflammatory Bowel Disease Center at Boston Medical Center and Professor of Medicine at the Boston University School of Medicine, who chairs the steering committee for the partnership between ACG, AGA, and the Foundation. “These projects were selected for their potential to overcome barriers by helping to identify and establish best practices around improving vaccine utilization and preventive health maintenance for patients with IBD. The selected projects also have the potential to be easily replicated, broadly disseminated, and widely adopted within the IBD community.”
The total funding related to this RFP is over $1 million, made possible through Pfizer Global Medical Grants. The awarded projects are:
Improving Vaccine Utilization and Preventive Health Maintenance in IBD 
Cedars-Sinai Medical Center
Project lead: Gil Y. Melmed, MD, FACG, AGAF
 	This proposal seeks to understand barriers to the uptake of preventive health measures among patients with IBD through patient focus groups; develop dynamic web-based interventions, including an interactive web site with animated video content, to overcome those challenges; and then test those interventions with a randomized, controlled trial in IBD Partners Patient-Powered Research Network. The primary outcome will be influenza vaccination uptake; secondary outcomes will include uptake of other recommendations including pneumococcal and zoster vaccination, bone health assessment, and skin cancer screening. If successful, these interventions will be freely promoted to optimize uptake in existing patient-education sites including You&IBD, IBD&Me, and IBD Partners.
Streamlining Preventive Health for Patients with IBD Through Effective Care Models, Evidence-based Guidelines, and Patient Engagement 
CME Outfitters LLC
Project lead: Miguel D. Regueiro, MD, FACG, AGAF, Cleveland Clinic
 	As part of the project to improve patient health, vaccination rates, and preventive services, educational interventions to health care professionals (HCPs) and patients are essential for change. Outside the clinic, digital health coaching presents the opportunity to supplement and support patient education, reinforcing the need to complete all necessary vaccinations among a group of 100 patients. Patient reported outcomes and feedback will be collected to assess improvements in vaccination and preventive health literacy, improvements in communication with providers, and shared decision-making.
Leveraging Digital Reporting and Shared Decision Making to Improve Vaccination and Preventive Health Maintenance in IBD
Icahn School of Medicine at Mount Sinai
Project Lead: Ashish Atreja, MD, MPH
 	The project goal is to develop and validate the use of patient-centered digital medicine technology to improve vaccination rates and preventive health compliance among IBD patients by developing a comprehensive intervention that includes self-assessment tracking as well as shared decision making. The overarching aim is to create a digital vaccination module for IBD patients and content for provider workshops that can serve as a freely available national resource for IBD centers, IBD practitioners, national organizations, and patients.
The projects were selected by an RFP steering committee representing key stakeholders, including gastroenterologists, an advanced practice provider, and an IBD patient: Francis A. Farraye, MD, MSc, FACG, AGAF (chair), Jean-Paul Achkar, MD, FACG, Kalee Eichelberger, Joseph D. Feuerstein, MD, Sunanda V. Kane, MD, FACG, AGAF, Geoffrey C. Nguyen, MD, PhD, AGAF,  and Ashley Perkovic, APN, FNP-BC.
Source: Crohns and Colitis Foundation

### Bacteria help discover human cancer-causing proteins
A team led by researchers at Baylor College of Medicine and the University of Texas at Austin has applied an unconventional approach that used bacteria to discover human proteins that can lead to DNA damage and promote cancer. Reported in the journal Cell, the study also proposes biological mechanisms by which these proteins can cause damage to DNA, opening possibilities for future cancer treatments.
"Our cells make protein carcinogens," said co-corresponding author Dr. Susan M. Rosenberg, Ben F. Love Chair in Cancer Research and professor of molecular and human genetics, of molecular virology and microbiology and of biochemistry and molecular biology at Baylor. "Cancer is a disease of mutations. A normal cell that has accumulated several mutations in particular genes becomes likely to turn into a cancer cell."
Mutations that cause cancer can be the result of DNA damage. External factors such as tobacco smoke and sunlight can damage DNA, but most DNA damage seems to result from events that occur within cells and is mediated by cellular components, including proteins. Despite the importance of these events, they have not been studied extensively.
"One way proteins can cause DNA damage is by being overproduced, which is a relatively frequent cellular event," said Rosenberg, who also is leader of the Cancer Evolvability Program at the Dan L Duncan Comprehensive Cancer Center at Baylor. "In this study, we set out to uncover proteins that, when overproduced by the cell, cause damage to DNA in ways that can lead to cancer."
To uncover these DNA "damage-up" proteins, the researchers took an unconventional approach. They searched for proteins that promote DNA damage in human cells by looking at proteins that, when overproduced, would cause DNA damage in the bacterium E. coli.
"Although bacteria and people are different, their basic biological processes are similar, so with this approach we thought we might find common mechanisms of DNA damage that could be relevant to cancer," Rosenberg said.
"This was a wild idea," said Rosenberg, and was possible because of funding from two sources aimed at trying high-risk strategies that, if successful, would have high impact: a National Institutes of Health Director's Pioneer Award and a gift from the W.M. Keck Foundation, among many other grants to the 16-lab team.
E. coli reveals novel candidates for cancer-promoting proteins
The researchers genetically modified bacteria so they would fluoresce red when DNA was damaged. Then, they overexpressed each of the 4,000 genes present in E coli individually and determined which ones made bacteria glow red.
"We uncovered an extensive and varied network of proteins that, when overproduced, alter cells in ways that lead to DNA damage," Rosenberg said. "Some of these proteins are, as expected, involved in DNA processing or repair, but, surprisingly, most are not directly connected to DNA. For instance, some of the DNA damage-up proteins participate in the transport of molecules across the cell membrane."
When the researchers looked for human protein relatives of the DNA "damage-up" proteins they had found in bacteria, they identified 284. Interestingly, they determined that these human proteins are linked to cancer more often than random sets of proteins. In addition, the proteins' RNAs, an indicator of protein production, predicted mutagenesis in tumors and poor patient prognosis. When the researchers overproduced these proteins in human cells in the lab, half of the proteins triggered DNA damage and mutation.
"We showed that E. coli can help to identify DNA damage-up proteins and mechanisms of action in human cells quickly and inexpensively. Some of the proteins and their mechanisms were known to be involved in cancer, but many others were not suspected of being in the cancer-causing list," said co-corresponding author Dr. Christophe Herman, professor of molecular and human genetics and molecular virology and microbiology at Baylor College of Medicine and member of the Dan L Duncan Comprehensive Cancer Center.
"I think it is extraordinary to identify so many ways DNA can be damaged. This study is opening up new avenues for discoveries of novel mechanisms that protect our genomes and how their dysfunction can alter the integrity of our DNA and cause cancer," said co-corresponding author Dr. Kyle M. Miller, associate professor of molecular biosciences at the University of Texas at Austin and member of the Dan L Duncan Comprehensive Cancer Center at Baylor. "It is yet another example of the power of model organisms to uncover basic biological processes that can shine a light on how human cells and cancer work."
"Our work has significant implications both in basic biological fields and in clinical research," Rosenberg said. "We provide a previously unknown understanding of the diverse mechanisms that can generate DNA damage leading to cancer. In the future, this finding may lead to new ways to identify people who are likely to develop cancer so that strategies to prevent it, slow it down or catch it early can be used."
Source: Baylor College of Medicine

### Scientists discover how 'superbug' E. coli clones take over human gut
A "superbug" clone of E. coli has evolved to prevent itself from becoming so dominant that it could potentially wipe out the bacteria from existence, scientists led by the University of Birmingham have discovered.
The researchers investigated how and why a clone of E. coli called ST131 has become the major cause of drug-resistant E. coli infections, but not so dominant that it has wiped out other clones that do not have multidrug resistance.
Escherichia coli (E. coli) is a type of bacteria common in human and animal intestines, and forms part of the normal gut flora, the bacteria that exist in the bowel. There are a number of different types of E. coli and, while the majority are harmless, some can cause serious food poisoning or infections including in the urinary tract or bloodstream.
The number of cases of E. coli have risen by 27% from 32,309 in 2012-13 to 41,060 in 2017-18. The rise has been linked to an increase in antibiotic resistant infections caused by so-called "superbugs."
"The most globally dominant clone of E. coli that is resistant to multiple drugs is called ST131," said Alan McNally, PhD, of the University of Birmingham's Institute of Microbiology and Infection.
"Earlier research has shown that while ST131 emerged and rapidly spread in the late 1990s, it caused no more than 20% of clinical cases of E. coli once it had emerged on the scene."
He continued, "Following our research, we now know that while there are significantly dominant drug resistant clones of E. coli such as ST131 and other new ones are emerging all the time, it seems highly unlikely that any of them are ever going to become a completely dominant clone because this process called NFDS controls the balance across the whole E. colipopulation."
Professor Jukka Corander, of the Wellcome Sanger Institute in Cambridge, the University of Oslo in Norway, and the University of Helsinki in Finland, said that as part of the research the scientists also analyzed almost 1,000 genome sequences of strains within ST131 to see if they could find any genetic patterns that may explain how this process happens.
"We found that in the ST131 clone there was a lot of variation in the genes that are involved in allowing the bacteria to colonize in the human gut when compared to those in non-drug resistant bacteria that are very closely related to ST131," he said.
"If a person is going to get a bloodstream or urinary infection from E. coli it usually comes after it has colonized in the gut, therefore we now know that genetically something has happened to this superbug which allows it to colonise the gut far more competitively than other E. coli."
He continued, "If we can understand why a multi-drug resistant E. coli out competes our resident healthy E.coli in the gut, we can try and find ways to prevent this from happening. This now needs to be the focus of further research."
The research, published in mBio, was also carried out in collaboration with the British Society of Antimicrobial Chemotherapy, the Wellcome Trust Sanger Institute, the London School of Hygiene and Tropical Medicine, and Imperial College London.
Source: University of Birmingham

### High-dose vitamin D shows benefit in patients with advanced colorectal cancer
Prompted by the "very encouraging" results of the SUNSHINE clinical trial, the potential benefits of vitamin D supplementation in metastatic colorectal cancer will be evaluated in a larger clinical trial planned to open at several hundred sites across the United States later this year, said Kimmie Ng, MD, MPH, director of Clinical Research in Dana-Farber's Gastrointestinal Cancer Center, and corresponding author of the SUNSHINE study. "To our knowledge, this study is the first completed randomized clinical trial of vitamin D supplementation for treatment of advanced or metastatic colorectal cancer," Ng said.
In the high-dose group, patients had a median delay of 13 months before their disease worsened; in the low-dose group, the median delay was 11 months. In addition, patients in the high-dose vitamin D group were 36 percent less likely to have disease progression or death during the follow-up period of 22.9 months. The trial included too few patients to determine whether those who took high-dose vitamin D experienced improved overall survival.
"The results of our trial suggest an improved outcome for patients who received vitamin D supplementation, and we look forward to launching a larger trial to confirm these exciting and provocative findings," said Charles Fuchs, MD, MPH, formerly of Dana-Farber as senior author of the study and now Director of Yale Cancer Center.
The initial findings were reported at the 2017 meeting of the American Society of Clinical Oncology. Those results, along with additional data, are now being published in JAMA.
The SUNSHINE trial randomized 139 patients with previously untreated metastatic colorectal cancer. One group took pills containing 4,000 international units (IU) of vitamin D per day along with standard chemotherapy, while the other group took 400 units (about the dose found in a multivitamin) along with chemotherapy.
Vitamin D, which is necessary for bone health, is made in the body through a chemical reaction dependent on sun exposure and is contained in some foods. In laboratory studies, vitamin D has demonstrated anti-cancer properties such as triggering programmed cell death, inhibiting cancer cell growth and reducing metastatic potential. Prospective observational studies have linked higher blood levels of vitamin D with a lower risk of colorectal cancer and improved survival of patients with the disease, but those studies could not prove that vitamin D was the cause.
Against this backdrop, the randomized, prospective phase 2 SUNSHINE trial recruited patients at 11 academic and community centers across the United States to test whether vitamin D supplementation can improve outcomes in patients with metastatic colorectal cancer. All patients received standard chemotherapy with a regimen called mFOLFOX6 plus bevacizumab. Patients in the high-dose vitamin D group initially took 8,000 IU a day for 14 days, then 4,000 IU a day thereafter. The low or standard-dose vitamin D group took 400 IU daily during all cycles. All patients were asked not to take any other vitamin D or calcium supplements during the trial period.
The trial's primary outcome measure was progression-free survival - the time until the disease began to worsen, or death - which was longer in the high-dose group. Another measure that was calculated - the hazard ratio for disease progression or death - revealed 36 percent lower odds in the high-dose group.
The researchers also sampled patients' blood to measure changes in the levels of 25-hydroxyvitamin D [25(OH)D], which is a standard test to determine a person's vitamin D status. This test showed that only 9 percent of the patients in the clinical trial had sufficient vitamin D at the beginning of treatment. Over the course of the study, patients receiving low-dose had no substantial change in their vitamin D levels, while those in the high-dose group soon reached the vitamin D-sufficient range and maintained it.
Analysis of the results showed that the benefit of high-dose vitamin D appeared to be less in patients who were obese, and those whose tumors contained a mutated KRAS gene, suggesting "that certain subsets of patients may need even higher doses of vitamin D for anti-tumor activity," the researchers said. They cautioned, however, that high doses of vitamin D shouldn't be taken except within the context of a clinical trial.
The study and its findings are "extremely important," Ng said, because "it identifies a cost-effective, safe, and easily accessible agent as a potential new treatment for metastatic colorectal cancer. This could therefore potentially have a large and wide-reaching impact globally, regardless of a patient's socioeconomic status or a country's resources."
Source: Dana-Farber Cancer Institute

### Aspirin to prevent colon cancer underutilized in high-risk patients
To explore whether patients are adhering to these USPSTF recommendations and guidelines, researchers from Florida Atlantic University's Schmidt College of Medicine analyzed data from structured interviews on 84 patients, ages 40 to 91 years old, with biopsy-proven advanced colorectal polyps between July 1, 2013 to June 30, 2017.
The data, which were published in the American Journal of Medicine, showed that only 36 (42.9 percent) of the 84 patients with advanced colorectal polyps reported taking aspirin.
"These data indicate underutilization of aspirin to prevent colorectal cancer as well as recurrent polyps in these high risk patients," said Charles H. Hennekens, M.D., Dr.P.H., senior author, the first Sir Richard Doll Professor, and senior academic advisor in FAU's Schmidt College of Medicine.
Co-authors include the first author, Benjamin Fiedler, a senior at Cornell University who has been accepted as a first-year medical student at the Schmidt College of Medicine; Lawrence Fiedler, MD, a gastroenterologist and affiliate associate professor; Michael DeDonno, PhD, assistant professor; Kosi Anago, MD, a former internal medicine resident; Leonie de la Cruz, a former medical student; and George R. Luck, MD, associate professor, all in FAU's Schmidt College of Medicine.
"These data pose major challenges that require multifactorial approaches by clinicians and their patients," said Benjamin Fiedler. "These approaches should include therapeutic lifestyle changes, adjunctive drug therapies as well as screening."
Therapeutic lifestyle changes of proven benefit include avoiding and treating overweight and obesity as well as regular physical activity and adjunctive drug therapies including aspirin.
"By utilizing these multifactorial approaches, we believe that these efforts should achieve the most good for the most patients concerning the prevention as well as screening and early diagnosis and treatment of colorectal cancers," said Hennekens, who has done ground-breaking research on the benefits of statins, aspirin, angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs) as well as beta adrenergic blockers -- all of which play major roles in decreasing premature deaths from heart attacks and strokes.
Hennekens was the first to demonstrate that aspirin significantly reduces a first heart attack as well as recurrent heart attacks, strokes, and cardiovascular death when given within 24 hours after onset of symptoms of a heart attack as well as to a wide variety of patients who have survived a blockage in the heart, brain or legs. His landmark and first discoveries on aspirin are not limited to cardiovascular disease and include the prevention of recurrent migraine headaches.
He also hypothesized from earlier observational study data that aspirin may decrease risks of colorectal cancer and delay cognitive loss as well as reduce the development of type 2 diabetes. Since then, randomized trials and their meta-analyses have indicated that aspirin prevents colorectal polyps as well as colorectal cancer.
"More than 90 percent of patients diagnosed with colorectal cancer are 50 years or older. The major risk factors are similar to those for heart attacks and stroke and include overweight, obesity as well as physical inactivity, a diet low in fiber and high in fat as well as type 2 diabetes," said Lawrence Fiedler, MD.
According to the U.S. Centers for Disease Control and Prevention, additional risk factors include inflammatory bowel disease such as Crohn's disease or ulcerative colitis; a personal or family history of colorectal cancer or colorectal polyps; and a genetic syndrome such as familial adenomatous polyposis or hereditary non-polyposis colorectal cancer (Lynch syndrome).
Source: FLORIDA ATLANTIC UNIVERSITY

### Results of early endoscopic exam critical for assessment of Barrett's patients
A new study indicates that both high-grade abnormal cellular changes (dysplasia) and esophageal adenocarcinoma (a form of cancer) have increased in the last 25 years among people with a digestive condition known as Barrett's esophagus. The study report, Increasing prevalence of high-grade dysplasia and adenocarcinoma on index endoscopy in Barrett's esophagus over the past 2 decades, is published in the February issue of GIE: Gastrointestinal Endoscopy, the peer-reviewed journal of the American Society for Gastrointestinal Endoscopy (ASGE).
The Barrett's Esophagus Study looked at more than 3,600 patients at multiple healthcare centers who had Barrett's esophagus (BE). This is a condition in which the normal tissue that lines the esophagus (the tube that carries food from the mouth to the stomach) develops abnormal changes. A significant percentage of people who have chronic symptoms of gastroesophageal reflux disease (GERD) will develop Barrett's esophagus.
The researchers looked at the index endoscopy findings of BE patients.
Endoscopy is a medical procedure in which doctors insert a tube with a camera at the end into the patient's digestive tract to look for visible problems or changes. Sometimes the doctor can treat a problem area while doing the endoscopy. The "index endoscopy" is one that is performed when a patient first complains of symptoms that need to be checked. The index endoscopy may be used later to compare to the results of successive endoscopies if those are recommended.
In this study, the researchers reviewed the index endoscopy results of the BE patients to determine the proportions of those with no dysplasia, low-grade dysplasia (LGD), high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC).
A look at these patients' records over 25 years indicated that over time, there was an increase in the mean age of patients with BE, and the proportion of males diagnosed with BE also increased. The proportion of patients who had low-grade dysplasia had remained stable, but there was a 148 percent increase of those with high-grade dysplasia and a 112% increase of those with EAC. Higher-grade dysplasia presents a higher risk for developing into cancer. There also was a marked increase in the number of visible lesions (areas of damaged tissue) detected during the endoscopy.
There was a decrease in the mean "BE length," meaning how many centimeters of the lining of the esophagus appear to be changed.
According to the study authors, these results suggest that the prevalence of HGD and EAC has significantly increased over the past 25 years despite a decrease in BE length during the same period. This increase parallels an increase in the detection of visible lesions, suggesting that a careful examination at the index endoscopy is crucial.
Source: American Society for Gastrointestinal Endoscopy

### 7 Day Indicator Hangtime Label
Healthmark is pleased to announce the new the 7 Day Time Indicator Hangtime Label to its Endoscopy product line.
Designed as a visual reminder for healthcare workers, the 7 Day Indicator Hangtime Label features a 7-day elapsed time indicator adhered to a green 8.5 x 2.5 inch self-looping label.
To activate the indicator simply press the blister on the strip, and upon activation a safe dye migrates along a seven-day display run-out window, which shows elapsed time. No preconditioning is required, there are no moving parts, and no power source is required.
Visit www.hmark.com or call 800-521-6224 for more information.
 

### When tempers flare, nurses' injuries could rise
A new study by researchers at Michigan State University and Portland State University has found that when there's an imbalance in support among nurses at work, tempers flare and risk of injuries can go up.
"Beyond the physical demands of the job, social factors can pose additional risks for nurses to experience muscle and joint pain in the shoulders, arms, hands and lower back," said Chu-Hsiang (Daisy) Chang, associate professor of psychology at MSU. "These types of musculoskeletal disorders often are worsened by feelings of anger."
Chang led the study, published in the journal Work and Occupations, with Liu-Qin Yang, associate professor of industrial-organizational psychology at Portland State University, and MSU doctoral student Taylor Lauricella.
Social factors can include perceptions around how much support someone is giving their co-workers and whether they perceive that same support is available to them. Types of support can come in many forms, including showing empathy and concern, offering advice, guidance and suggestions, or providing a helping hand.
"The imbalance occurs when nurses believe that the support they've received is less than what they've given to their co-workers," Yang said. "This imbalance results in nurses being angry at their peers and overall work situation."
Nursing often ranks among the worst occupations in terms of work-related injuries because of the physical demands during long,12-hour shifts.
The study surveyed more than 400 nurses in two hospitals from 29 different units to further explore the effect psychological factors in a work environment had on physical health. It found that when nurses believed they should receive the same amount of support uniformly, tempers rose if an imbalance occurred.
"If the norm is that everyone gets the same amount of support, then an individual nurse who experiences an imbalance might wonder why she's being singled out," Yang said. "She'll feel worse and angrier."
In instances where differences in support is the expectation, then lower levels of anger were reported.
Yang said that in this scenario, individual nurses are less sensitive to an imbalance of support at the personal level.
"Hospitals need to implement strategies and interventions that are designed to improve the social environment for nurses," Chang said. "Doing so may not only improve psychological well-being and reduce their stress, but also promote their physical health."
According to Chang, hospitals use a variety of solutions to address injuries, but they focus more on physical job tasks to eliminate risk, such as using lift devices to help transfer patients from a bed to a wheelchair.
"Ensuring fair treatment or distribution of workload in a social context could be a good strategy that can reduce feelings of anger and ultimately, have an indirect effect on reducing injury complaints, too," Chang said.
Source: Michigan State University

### Fasting-mimicking diet holds promise for people with digestive problem
What if a special diet could reduce inflammation and repair your gut?
University of Southern California (USC) researchers provided evidence that a low-calorie “fasting-mimicking” diet has the potential to do just that. Published in the journal Cell Reports, the study reports on the health benefits of periodic cycles of the diet for people with inflammation and indicated that the diet reversed inflammatory bowel disease (IBD) pathology in mice.
Results showed that fasting-mimicking diet caused a reduction in intestinal inflammation and an increase in intestinal stem cells in part by promoting the expansion of beneficial gut microbiota. Study authors say the reversal of IBD pathology in mice, together with its anti-inflammatory effects demonstrated in a human clinical trial, indicate that the regimen has the potential to mitigate IBD.
“This study for the first time combines two worlds of research,” said Valter Longo, a study author and the director of the USC Longevity Institute at the USC Leonard Davis School of Gerontology and professor of biological sciences at the USC Dornsife College of Letters, Arts and Sciences. “The first is about what you should eat every day, and many studies point to a diet rich in vegetables, nuts and olive oil. The second is fasting and its effects on inflammation, regeneration and aging.”
By combining these fields of research using the fasting-mimicking diet, the authors were able to reduce the inflammation and pathology associated with intestinal diseases.
Longo said for people with a poor diet, a “once in a while” fix is the periodic use of a low-calorie, plant-based diet that causes cells to act like the body is fasting. Earlier clinical trials conducted by Longo and colleagues allowed participants to consume between 750 and 1,100 calories per day over a five-day period and contained specific proportions of proteins, fats and carbohydrates. Participants saw reduced risk factors for many life-threatening diseases.
“Fasting is hard to stick to and it can be dangerous,” Longo said. “We know that the fasting-mimicking diet is safer and easier than water-only fasting, but the big surprise from this study is that if you replace the fasting-mimicking diet, which includes pre-biotic ingredients, with water, we don’t see the same benefits.”
In the study, one group of mice adhered to a four-day fasting-mimicking diet by consuming approximately 50 percent of their normal caloric intake on the first day and 10 percent of their normal caloric intake from the second through fourth days. Another group fasted with a water-only diet for 48 hours.
The study demonstrated that two cycles of a four-day fasting-mimicking diet followed by a normal diet appeared to be enough to mitigate some, and reverse other, IBD-associated pathologies or symptoms. In contrast, water-only fasting came up short, indicating that certain nutrients in the fasting-mimicking diet contribute to the microbial and anti-inflammatory changes necessary to maximize the effects of the fasting regimen.
“We’ve determined that the dietary components are contributing to the beneficial effects; it’s not just about the cells of the human body but it’s also about the microbes that are affected by both the fasting and the diet,” Longo said. “The ingredients in the diet pushed the microbes to help the fasting maximize the benefits against IBD.”
The research team observed activation of stem cells and a regenerative effort in the colon and the small intestine, which increased significantly in length only in the presence of multiple cycles of the fasting-mimicking diet. They concluded that fasting primes the body for improvement, but it is the “re-feeding” that provides the opportunity to rebuild cells and tissues.
“It is really remarkable, that in the past 100 years of research into calorie restriction, no one recognized the importance of the re-feeding,” Longo said. “Restriction is like a demolition where you take the building down. But you have to rebuild it. If you don’t do that, there’s no benefit. You are left with an empty lot, and what have you achieved?”
In the current and previous studies, the authors showed that in patients with elevated C-reactive protein, a marker for inflammation, fasting-mimicking diet cycles are able to reduce C-reactive protein and reverse the associated increase in white blood cells. Together with the results in mice, these data indicate that fasting-mimicking diet cycles have the potential to be effective against human IBD, including Crohn’s disease and ulcerative colitis.
IBD afflicts an estimated 1.6 million Americans and is associated with acute and chronic inflammation of the intestine. Study authors say a randomized clinical trial involving the use of fasting-mimicking diet cycles to treat IBD is necessary to determine the safety and efficacy of these dietary treatments in humans, and are currently finalizing a clinical trial protocol.
Source: University of Southern California

### Colorectal cancer in patients with early onset is distinct from that in older patients
New research indicates that colorectal cancer diagnosed at an early age has clinical and genetic features that are different from those seen in traditional colorectal cancer diagnosed later in life. Published early online in CANCER, a peer-reviewed journal of the American Cancer Society, the study also revealed certain unique features in especially young patients and those with predisposing conditions.
Although incidence and mortality rates of colorectal cancer have fallen in patients aged 50 years and older, early-onset colorectal cancer rates have been increasing over the past two decades. To look for differences between early-onset and late-onset colorectal cancer, investigators at The University of Texas MD Anderson Cancer Center in Houston analyzed information on more than 36,000 colorectal cancer patients.
The researchers found that younger patients were more likely to have certain genetic mutations and certain subtypes of colorectal cancer than older patients. Also, among patients with early-onset colorectal cancer, very young patients (aged 18-29 years) were unique from older patients (aged 30-49 years) in terms of the clinical and genetic features of their cancer. Likewise, patients with early-onset colorectal cancer who had predisposing conditions, such as inflammatory bowel disease, had different clinical and genetic characteristics compared with patients without predisposing conditions.
"We need to appreciate that there are unique biologic subtypes within young patients that may affect how their cancers behave and may require a personalized approach to treatment," said senior author Jonathan Loree, MD. "Going forward, special clinical consideration should be given to, and further scientific investigations should be performed for, both very young patients with colorectal cancer and those with predisposing medical conditions."
March is Colorectal Cancer Awareness Month.
Source: Wiley

### New Foam Instrument Protection
Healthmark has announced the addition of the Foam Protectors to its ProSysTM Instrument Care product line. Manufactured from open cell, polyurethane foam, the blue latex-free Foam Protectors are designed to help prevent costly damage to instruments caused by shifting during transport, handling and sterilization. The Foam Protectors are available in the following styles: Pouch, Tip Protector, Pinhole Holder, Corner Protectors, and a 12 Instrument Foam Protector.
Visit www.hmark.com or call 800-521-6224 for more information.

### How a common oral bacteria makes colon cancer more deadly
Researchers at the Columbia University College of Dental Medicine have determined how F. nucleatum--a common oral bacteria often implicated in tooth decay--accelerates the growth of colon cancer. The study was published online in the journal EMBO Reports.
The findings could make it easier to identify and treat more aggressive colon cancers. It also helps explain why some cases advance far more quickly than others, thanks to the same bacteria found in dental plaque.
Colon cancer is the second leading cause of cancer death in the U.S. Researchers have long known that the disease is caused by genetic mutations that typically accumulate over the course of a decade.
"Mutations are just part of the story," said study leader Yiping W. Han, PhD, professor of microbial sciences at Columbia University's College of Dental Medicine and Vagelos College of Physicians & Surgeons. "Other factors, including microbes, can also play a role."
Scientists have also demonstrated that about a third of colorectal cancers are associated with a common oral bacterium called F. nucleatum. Those cases are often the most aggressive, but nobody knew why. In a prior study, Han's research team discovered that the bacterium makes a molecule called FadA adhesin, triggering a signaling pathway in colon cells that has been implicated in several cancers. They also found that FadA adhesin only stimulates the growth of cancerous cells, not healthy cells. "We needed to find out why F. nucleatum only seemed to interact with the cancerous cells," said Han.
In the current study, the researchers found in cell cultures that noncancerous colon cells lack a protein, called Annexin A1, which stimulates cancer growth. They then confirmed both in vitro and later in mice that disabling Annexin A1 prevented F. nucleatum from binding to the cancer cells, slowing their growth.
The researchers also discovered that F. nucleatum increases production of Annexin A1, attracting more of the bacteria. "We identified a positive feedback loop that worsens the cancer's progression," said Han. "We propose a two-hit model, where genetic mutations are the first hit. F. nucleatum serves as the second hit, accelerating the cancer signaling pathway and speeding tumor growth."
The researchers then looked at an RNA-sequencing dataset, available through the National Center for Biotechnology Information of 466 patients with primary colon cancer. Patients with increased Annexin A1 expression had a worse prognosis, regardless of the cancer grade and stage, age, or sex.N
The researchers are currently looking for ways to develop Annexin A1 as a biomarker for more aggressive cancers and as a potential target for developing new treatments for colon and other types of cancer.
Source: Columbia University College of Dental Medicine

### TBJ NEW SCOPE PRE-CLEANING SINKS
TBJ’s new Scope Pre-Cleaning sink product line provides a comprehensive, integrated flexible endoscope pre-cleaning system that greatly improves the speed of endoscope reprocessing.  Features integrated in to the sink include leak testing, automatic sink bowl filling, precision chemical dosing, automated channel flushing with pulsating fluid technology and a data management system. An optional barcode scanner reduces the time to input scope serial numbers and technician I.D.s. Single, double and triple bowl configurations available.  The double bowl sink design is shown here.  Sink designs can be customized around your specific needs.  Contact us today at 717-261-9700 or through our web site at www.tbjinc.com.

### Sinister blastocystis: a clandestine killer of good bacteria revealed
Since most of the microbes in our gut are bacteria, they tend to hog much of the microbiome research limelight. But, lurking amongst the bacteria are other microbes such as single-cell eukaryotes (SCE) and viruses, which have been largely ignored until now.
If doctors and scientists think of Blastocystis (one the most common gut SCEs) at all, they often regard it as a harmless commensal organism, peacefully co-existing with its bacterial neighbors. However, that could change with the publication of a new study from NUS Medicine (online in Microbiome on March 11, 2019), which shows that a subtype of Blastocystis isolated from Singapore can actually harm its neighbors and its home in an insidious way.
Associate professors Kevin Tan and Zhang Yongliang from the Department of Microbiology and Immunology at NUS Medicine, together with postdoctoral research associates John Yason and Chin Wen Png, demonstrated that Blastocystis subtype 7 (ST7) selectively caused the death of Bifidobacterium (one of the "good" bacteria in the body) in cell culture and in vivo.
The ST7 strain of Blastocystis appeared to induce oxidative stress mechanisms, which involve the release of reactive oxygen species (ROS). These killer molecules caused the death of the good Bifidobacterium. Interestingly, the Blastocystis ST7 organisms also reduced the population of Lactobacillus (another good bacteria) in vivo, although the mechanism of killing is still unknown.
Bifidobacterium and Lactobacillus are considered good bacteria because they maintain the integrity of the intestinal lining by supporting tight junctions, which act like cement between the cells that make up the lining. They are also commonly used as probiotics to promote gut health. Besides killing Bifidobacterium directly, Blastocystis ST7 can also gang up with E. coli in the gut to kill even more of these protectors. Ironically, Bifidobacterium and E. coli both help Blastocystis grow better. In other words, Bifidobacterium promotes the growth of its own killer.
To make matters worse, Blastocystis ST7 injures the gut lining directly as well as indirectly by triggering an inflammatory response (Figure), causing lesions (ulcers) and a disordered structure of the intestinal lining in vivo. Add to this the loss of the protective good bacteria, an infection with Blastocystis ST7 could be a recipe for long-term damage to the gut lining, possibly contributing to inflammatory bowel disease, irritable bowel syndrome, as well as gastrointestinal and colon cancers.
Part of the reason for the unclear role of Blastocystis in disease is that previous studies did not consider the Blastocystis subtype that was being investigated. Some subtypes are likely to be harmless, but this study shows that ST7 is uniquely different. Not only does ST7 have harmful effects, it is also resistant to metronidazole, the typical treatment for Blastocystis.
Like other Blastocystis subtypes, ST7 is transmitted through eating food that has been contaminated with feces from infected animals, especially birds. Although ST7 has been reported mainly in Singapore, it has also been described in Japan and at least one Danish study. Thus, this pathogenic Blastocystis subtype could be found in other ethnicities and geographic locations as it becomes more widely studied.
Tan is already developing tools to study the mechanisms by which Blastocystis cause disease in greater depth. He and his team have established a genetic modification system for Blastocystis, whereby foreign genes can be introduced into and expressed in Blastocystis and the effects of these changes can be studied. They hope to use this system to illuminate how Blastocystis interacts with its host to cause disease and to explore ways to combat the microbe.
"This is the first detailed study to show a causal link between Blastocystis, a common single cell eukaryote of the human gut, and the host microbiota. We reveal how it reduces the numbers of beneficial bacteria, which may in turn lead to an unbalanced gut microbiome and poorer gut health," Tan said.
The detrimental effects of Blastocystis on Bifidobacterium and Lactobacillus could facilitate the development of inflammatory bowel disease and irritable bowel syndrome, in which the good bacteria play a protective role. Based on these results, clinicians could also consider whether to exclude fecal transplants that contain specific subtypes of Blastocystis during fecal microbiota transplantation.
Source: National University of Singapore, Yong Loo Lin School of Medicine

### Faster results enable hospitals to test every single cycle to confirm sterility
IRVINE, Calif., June 21, 2017  -- Advanced Sterilization Products (ASP) today announced it has received FDA clearance for its 30-minute STERRAD VELOCITY™ Biological Indicator (BI) System. By reducing the time it takes to get results, from several hours to 30 minutes, this new enhancement to the company's complete sterilization ecosystem gives hospitals the opportunity to raise their standard of care by running a BI in every cycle, every day.
Ensuring that all surgical devices are properly sterilized is one-way healthcare workers can help reduce the incidences of healthcare-acquired infections (HAIs). HAIs have a devastating personal and economic impact, claiming the lives of 99,000 people in the U.S. each year1 at a cost of up to $45 billion.2 BIs help to prevent HAIs by providing assurance that instruments used on patients are sterilized. Hospital sterilization professionals will now be able to deliver instruments to the operating room faster and with greater peace of mind.
"With a significantly shorter wait time, STERRAD VELOCITY™ reduces the risk of hospital sterilization departments releasing instruments prior to BI confirmation," said Amy Smith, Vice President, ASP Global Marketing.  "Now they will finally be able to know with certainty that proper sterilization conditions have been achieved before the instruments are used in patients."
Earlier this year, ASP enhanced its overall sterilization solution with the full launch of STERRAD® Systems with ALLClear™ Technology and ASP ACCESS™, a smart information sharing technology. STERRAD VELOCITY™ is the only BI reader that can automatically communicate BI information to STERRAD® Systems, ITS and hospital networks, minimizing the need for manual documentation and reducing the potential for human error.
"As the only company that offers an integrated, end-to-end sterilization solution, ASP is in a unique position to help customers elevate patient safety while also maximizing compliance and efficiency in their daily routine," said Smith. "Our complete ecosystem is designed to work together to provide the most accurate results. This ensures the lives of patients are better protected at a time when they are already vulnerable – when they are in hospitals and undergoing potentially life-changing procedures."
About Advanced Sterilization Products (ASP)
Advanced Sterilization Products (ASP), a division of Ethicon US, LLC, part of the Johnson & Johnson Medical Devices Companies, has a long track record of designing and delivering innovative infection prevention solutions that dramatically raise the level of health care and safety for those who matter most. Our pioneering technology, global distribution and established leadership position enable us to simplify the process of buying and operating infection prevention products and services every day for thousands of medical facilities around the world. This enables our customers to focus on what they do best – preventing infection and saving lives. For more information, please visit https://www.us.aspjj.com/allclear or follow us on Twitter at www.twitter.com/ASPJJ.
STERRAD® is a registered trademark of Advanced Sterilization Products. STERRAD VELOCITY™, ALLClear™, and ASP ACCESS™ are trademarks of Advanced Sterilization Products.
Cautions Concerning Forward-Looking Statements
This press release contains "forward-looking statements" as defined in the Private Securities Litigation Reform Act of 1995 regarding performance expectations for the STERRAD® VELOCITYTM Biological Indicator (BI) System. The reader is cautioned not to rely on these forward-looking statements. These statements are based on current expectations of future events. If underlying assumptions prove inaccurate or known or unknown risks or uncertainties materialize, actual results could vary materially from the expectations and projections of Ethicon US, LLC or its affiliated entities including Johnson & Johnson.  Risks and uncertainties include, but are not limited to: uncertainty as to whether the STERRAD® VELOCITYTM Biological Indicator (BI) System will perform as expected; uncertainty of commercial success; challenges to patents; competition, including technological advances, new products and patents attained by competitors; manufacturing difficulties and delays; changes to applicable laws and regulations, including global health care reforms; changes in behavior and spending patterns of purchasers of health care products and services; and trends toward health care cost containment. A further list and descriptions of these risks, uncertainties and other factors can be found in Johnson & Johnson's Annual Report on Form 10-K for the fiscal year ended January 1, 2017, including under Item 1A, "Risk Factors," its most recently filed Quarterly Report on Form 10-Q, including under the caption "Cautionary Note Regarding Forward-Looking Statements," and the company's subsequent filings with the Securities and Exchange Commission. Copies of these filings are available online at www.sec.gov, www.jnj.com or on request from Johnson & Johnson.  Neither Johnson & Johnson and its affiliates do not undertake to update any forward-looking statement expressed in this release as a result of new information or future events or developments.
© Ethicon US, LLC 2017. All rights reserved. 074792-170615
 	https://www.cdc.gov/washington/~cdcatWork/pdf/infections.pdf,  accessed on 6/16/17
 	http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf, accessed on 6/16/17
 
SOURCE Advanced Sterilization Products

### Test for esophageal cancer could save millions of lives
Cancer of the esophagus claims more than 400,000 lives around the world each year. With no efficient, reliable method of screening for the disease, by the time symptoms become apparent, it's often too late to save the patient.
A Johns Hopkins researcher who has devoted his career to the detection and prevention of esophageal cancer today published a paper in the journal Clinical Cancer Research that he says could finally result in simple and inexpensive screening for the deadly disease.
In the article, gastroenterologist Stephen Meltzer, a professor of medicine and oncology at the Johns Hopkins University School of Medicine, along with a team of researchers, clinicians and biomedical engineers describe a test, the "EsophaCap," that uses specific genetic biomarkers to detect dangerous changes in the cells that line the inside of the esophagus.
Previous studies have demonstrated Meltzer's biomarkers' ability to detect a condition called Barrett's esophagus, which causes the body to replace the tissue that lines the organ with cells that can turn cancerous.
But large-scale methods to deploy those biomarkers as a screening tool have been elusive until now.
The principle behind the EsophaCap is simple, said Meltzer. The patient swallows a small capsule that has a long string attached to it. After the capsule makes its way down the esophagus and into the stomach - a process that takes only a minute or so - the gelatin coating on the capsule begins to dissolve.
From that capsule emerges a 2-centimeter polyurethane sponge, still attached to the string, much of which still hangs from the patient's mouth.
The screener gently pulls the string and the sponge begins its return journey, out of the stomach, into the esophagus and, finally, out of the patient's mouth.
As it makes its way up, the sponge comes into contact with the entire length and breadth of the esophagus, collecting genetic material all along the way. Then, as the sponge nears the top, the screener gives a final gentle tug, popping the sponge past the organ's upper sphincter muscle. The sponge emerges loaded with genetic material that holds the key to the patient's esophageal health.
The sponge is then sent to a company that performs simple genetic tests on the material to determine the patient's risk for esophageal cancer.
"Early detection is the whole ballgame when it comes to esophageal cancer," Meltzer said. "Patients have a much better chance to treat it--or even prevent it--if they know their risk. We believe this little sponge can bring easy and inexpensive screening to people around the world."
With nearly half a million new cases a year, esophageal cancer is the eighth most-common cancer worldwide, with the highest rates in parts of Africa and Asia.
In 2016, the United States saw nearly 17,000 new cases diagnosed and about 16,000 deaths from cancer of the esophagus. Those numbers have increased sharply in recent years.
The five-year survival rate for people with cancer confined to the esophagus is 43 percent. When it spreads to nearby tissues or organs, that rate falls to 23 percent. And esophageal cancer that spreads to distant parts of the body offers a five-year survival rate of only 5 percent.
In previous research, Meltzer has performed rigorous testing on the set of genetic biomarkers he uses to diagnose Barrett's esophagus. The gene combination of p16, NELL1, AKAP12 and TAC1 has yielded a sensitivity of nearly 92 percent and has offered reliable diagnoses.
Medicine has never had routine screening methods for the disease. Both endoscopy and biopsy are less-than-ideal, since they're inexact, expensive and rely on random tissue samples, rather than material from the whole esophagus lining.
"It's actually possible to miss early cancerous cells using endoscopy with biopsy and most patients with Barrett's don't ever undergo endoscopy," said Meltzer. "Right now, we're confident that we have the tools to identify this type of cancer. But we previously lacked a way to collect enough genetic material to confidently determine a patient's diagnosis. We believe that EsophaCap now provides a solution to this serious problem."
Meltzer administered the EsophaCap test to 94 people over the course of the study. Eighty-five percent of subjects were able to swallow the capsule, with 100 percent successful sponge retrieval. Endoscopic evaluation of the patients after EsophaCap administration, Meltzer reported, showed no evidence of bleeding, pain, trauma or other adverse reactions to the test.
In the journal article, Meltzer reports that of the patients able to swallow the capsule, nearly half would be diagnosed with Barrett's esophagus--a rate far higher than that of the general U.S. population. He notes that most patients enrolled in the study were being treated for gastrointestinal symptoms.
"That may explain why we saw a rate of Barrett's esophagus that was higher than in the general population," he said.
Source: Johns Hopkins Medicine

### CLEAN Bag
Healthmark Industries has announced the addition of the new Self-Seal CLEAN Bag to its Bags & Dust Covers product line.
Storing reprocessed healthcare products appropriately is crucial to avoid environmental contamination. The new Self-Seal CLEAN Bag has been created to keep items covered after reprocessing. The 8” x 14” tamper evident self-seal bags are clear and printed with “CLEAN” in green lettering for easy identification of contents and “clean” status. They are Ideal for transportation and storage.
Visit www.hmark.com or call 800-521-6224 for more information.

### New study shows sitting, watching TV linked to colorectal cancer risk before age 50
A new study in JNCI Cancer Spectrum has identified a connection between prolonged time spent sitting while watching TV and increased risk of colorectal cancer for younger Americans.
Young-onset colorectal cancer, diagnosed under age 50, is increasing in the US and globally, sharply contrasting with the dramatic decreases among older people, largely as a result of cancer screening initiatives.
Young-onset colorectal cancer has potentially different molecular characteristics compared to those of late-onset, and is typically more aggressive and found at a more advanced stage than those in older patients, resulting in greater years of life lost. Despite these trends, researchers have identified few risk factors specific to young-onset colorectal cancer.
Researchers here studied sedentary TV reviewing time, as well as other sedentary behaviors, in 89,278 American women in the Nurses' Health Study II. Of the 118 cases of young-onset colorectal cancer diagnosed over two decades of follow up, more than one hour of daily TV viewing time was associated with a 12% increase in risk compared to those who watched less.
The results were even more striking for those watching more than two hours/day with a nearly 70% increase in risk. This association was independent of BMI and exercise and was consistently observed among women without a family history of colorectal cancer. The association was also more pronounced for rectal cancer compared to colon cancer.
These findings are among the first to link specific sedentary behavioral patterns with risk of young-onset colorectal cancer.
"This study may help identify those at high risk and who might benefit more from early screening," said Yin Cao, assistant professor of surgery at Washington University School of Medicine, and the study's co-senior author. "The fact that these results were independent of BMI and physical activity suggests that being sedentary may be an altogether distinct risk factor for young-onset colorectal cancer."
Source: OXFORD UNIVERSITY PRESS

### SGNA 2020 is still a go... for now
NEW DATES ANNOUNCED
The health and safety of our conference attendees and industry partners is of the utmost importance to the SGNA Board of Directors and management staff. It is our goal to create a healthy and safe environment where our attendees and industry partners can enjoy the 2020 Annual Course with confidence and derive value from their experiences.
Based on the information currently available, the 2020 SGNA Annual Course is moving forward as planned at this time. SGNA will continue to closely monitor the situation related to COVID-19, and assess new information and guidelines from the local Louisville health authorities, the U.S. Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) as it is released. As new information becomes available, we will evaluate the relevancy related to the Annual Course, and will communicate any change in plans necessitated by the evolving situation as quickly as possible.
Thank you for your patience as we work to determine the best course of action. We appreciate and understand that, as our prospective attendees and exhibitors/sponsors, your planning is impacted by our decisions, and you have made a significant investment to increase your exposure to our event attendees. While the standard cancelation mentioned in the SGNA Rules & Regulation policy applies we will investigate other options for reaching our members should holding the May event become impossible.

### A reservoir of bacteria: Sink drains next to toilets in patient rooms may harbor dangerous organisms
Sinks situated next to patient toilets in hospital rooms may be reservoirs for Klebsiella pneumoniae carbapenemase (KPC), increasing the risk of dangerous germ transmission, according to new research published in the American Journal of Infection Control (AJIC), the journal of the Association for Professionals in Infection Control and Epidemiology.
The study found a high prevalence of KPC positivity in sink drains located next to toilets. Of the samples tested, 87.0 percent of patient sinks next to toilets tested positive for KPC -- in stark comparison to the 21.7 percent of sink drains located closer to the entry door of the room.
Klebsiella is a type of bacteria that can cause a number of healthcare associated infections, such as pneumonia, bloodstream infections, wound infections, or surgical site infections. Increasingly, Klebsiella bacteria have developed antimicrobial resistance, most recently to the class of antibiotics known as carbapenems.
In four of five rooms in which the entry-door sink tested positive, the sink near the toilet was also positive, suggesting a potential source for cross-contamination within the same room.
Researchers in Milwaukee, Wisconsin performed the study in the medical intensive care unit (MICU) of a 600-bed Wisconsin hospital. The MICU did not have any documented interactions with KPC-producing organisms within the past year.
"This study, if validated, could have major implications for infection control," agree study authors, Blake Buchan, PhD, and Silvia Munoz-Price, MD, PhD. "If sinks next to toilets are indeed a reservoir for KPC, additional interventions - such as modified hand hygiene practices and sink disinfection protocols - may be needed to stem the risk of transmission among healthcare providers and patients alike."
This is the first study to directly examine the relevance of sink proximity to toilets in patient rooms. The researchers point out that while it is not clear how contamination occurs, it is plausible that biofilms growing in pipes shared between toilets and sinks or that flushing generates contaminated drops that reach the sink drains.
"The results of this study demonstrate the importance of remaining vigilant to potential areas of cross-contamination," said 2019 APIC President Karen Hoffmann, RN, MS, CIC, FSHEA, FAPIC. "Maintaining a strong understanding of environmental risks is critical to protecting patient safety, and this is yet another example of how germs can lurk in often the most unexpected of places."
Source: ELSEVIER
 

### Window Style Tip Protector
Healthmark Industries has announced the new Window Style Tip Protector to their ProSys™ Instrument Care product line. Certain medical devices and instruments are a bit more delicate than others, and thus require equally delicate care and reprocessing practices.
The single-use Window Style Tip Protector is designed for protection of small sharp and fragile surgical instruments during the sterilization process. Manufactured from paper, the 50 x 125 mm Window Style Tip Protectors come with a 32mm wide slot for placement of instruments and features a transparent polyethylene pouch that secures the tip of the instrument in place to prevent from sliding around or out. The Window Style Tip Protectors are heat resistant up to 275˚ F and available for purchase in a box of 100.
Visit www.hmark.com or call 1-800-521-6224 for more information.

### Better assessing bacteria sensitivity to antibiotics could change how drugs are prescribed
We rely on antibiotics to treat bacterial infections, but the rise of antibiotic-resistant bacteria forces doctors and patients to contend with shifting treatment plans. Furthermore, current laboratory tests to determine what bacteria is causing a particular infection takes days to complete and, in cases of serious infection, the results are often too late for the patient.
Mechanical engineers from the Korea Advanced Institute of Science and Technology recently developed a microchip antibiotic testing platform that takes only six to seven hours to determine the appropriate medication.
"Trying to figure what drug to use at what dosage, in the fastest time possible, is key in successfully treating bacterial infections," said Jessie Jeon, an author on the paper.
Clinicians often treat life-threatening infections with a cocktail of antibiotics, hoping that one of the antibiotics will stop the bacterial infection. However, blanket-prescribing antibiotics contributes to the rise in bacterial resistance.
"Figuring out the effect of different combinations of drugs in a simple manner is likely to have a big impact on health," said Jeon. She explained that her team's speedy microfluidic system was the first for which combinatorial treatments had been tested.
The speed and success of the Korean team's new antibiotic susceptibility testing system is due to two key innovative design features.
The first feature was developing an antibiotic dosage range, crucial for calculating the minimum inhibitory dosage that prevents bacterial growth. By continually pumping antibiotics through the half-millimeter-wide channels in the microchip, the team establishes a dosage range through microchip within 30 minutes. A critical time saver, the dosage range enabled the team to determine the minimum inhibitory dosage within a single test.
The second feature was using a convenient method to quantify bacterial growth within the microchip. Images were taken of the agar-encased bacteria and the difference in color between areas of agar at a higher antibiotic concentration, where no bacteria grew (which were dark), and the more reflective white regions, where bacterial colonies grew more easily, was quantified on a position-specific grayscale.
Alignment of the five antibiotics tested in this new system with the clinical gold standard measurements suggests that the microchip system is sensitive enough for clinical application, Jeon added.
"We can see that our assembly works pretty robustly with a single drug, and have also shown it can work with two drugs; now we want to further optimize the application to combinatorial drugs," said Jeon.
Source: AMERICAN INSTITUTE OF PHYSICS

### Study reveals unsettling multidrug antibiotic resistance in remote Arctic soil microbes
A University of Kansas geologist's work in the remote High Arctic of Norway has exposed the startling global spread of antibiotic-resistant microbes -- including multidrug-resistant "superbugs" -- that could have dire implications for human health worldwide.
Jennifer Roberts, professor and chair of geology at KU, began by investigating the microbial geochemistry of thawing permafrost and its release of methane, a powerful greenhouse gas that speeds global climate change.
But follow-up analysis of the soil samples Roberts collected in the Kongsfjorden region of Svalbard, Norway, also showed that antibiotic-resistant genes have transferred into soil-microbe populations in one of Earth's most remote locations. The findings by Roberts and an international team of colleagues from the United Kingdom and China were just published in the peer-reviewed journal Environment International.
"The study offered a good opportunity to test soil samples for antibiotic genes with the hypothesis that Svalbard was such a remote and isolated place, we wouldn't find any evidence of such genes," Roberts said. "In contrast, we found quite a few including superbug antibiotic-resistant genes like the New Delhi gene, which first emerged in India not very long ago. This was a surprise -- the genes we found clearly had a short transfer time between being discovered in India and our group detecting them in the Arctic only a few years later."
The research team genetically sequenced DNA from 40 samples of soil at eight locations in Svalbard, finding 131 antibiotic-resistant genes. One antibiotic-resistant gene found is called blaNDM-1. Initially detected in New Delhi in 2007, the gene triggers resistance to carbapenem antibiotics -- a last-resort remedy for otherwise untreatable infectious disease. The demonstrated spread of blaNDM-1, in particular, is highly concerning, drawing attention to the rising crisis of global antibiotic resistance.
The researchers say the antibiotic-resistant genes could have taken only a few pathways to the Arctic.
"They likely originated from pathogens that were exposed multiple times to different types of antibiotics -- that's how we get these acutely antibiotic-resistant strains, where they persist even despite the use of 'last-resort' treatments," Roberts said. "Some of the sites where we found the New Delhi strain of gene aren't terribly far from the main research base, so there's a possibility human waste was involved. We also observed colonies of nesting birds in low-elevation places, like small lakes and other sources of open water during maximum thaw, and that was where we saw the highest concentrations of these genes. We also detected them in places that didn't have open water but had a lot of small animals like foxes, and you can trace a vector between a watering hole or small lake where you have lots of birds and small mammals going to drink and then picking up whatever genes are there."
Roberts, whose research expertise is in hydrochemistry and microbial geochemistry, worked to develop a benchmark for antibiotic-resistant genes naturally found in Svalbard so the team could distinguish them from "foreign" multidrug-resistant genes transferred to the Arctic from regions where antibiotics are used in human and animal populations to treat disease.
"Because the migration of these genes is of such great concern, the next question becomes, 'Are these antibiotic-resistant genes native -- or did they get transferred?'" she said. "My role was to use lines of evidence in our research to help us be clear about what was a native gene that developed in soil and what was brought in from other sources. We did that by looking at nutritional supplies in soil, which are very, very low in these Arctic soils. We were then able to link the antibiotic-resistant genes to what appears to be a new source of phosphate being brought in from outside -- and the most likely source of phosphate is feces, either in human sewage or, more than likely, bird guano."
According to Roberts, antibiotic resistance traveled between microbes via "lateral gene transfer." In this process, pathogens travel into water through feces, die and release large quantities of free genetic material into the water. This genetic material does not easily degrade, with the result that other organisms end up picking up the genes -- as well as their resistance.
"It's not that we have some kind of robust community of E. coli or other pathogen living in the surface waters in the Arctic," Roberts said. "Instead, some antibiotic-resistant pathogen was brought in from outside sources -- and now that resistance has been dispersed as genes are picked up by other organisms that were already populous in the environment."
Roberts said the team's discovery shows multidrug antibiotic resistance is now global in nature.
"We have to remember that we got antibiotics, like penicillin, from soil microorganisms to begin with," she said. "Microorganisms have used resistance capabilities to overcome immunities in the environment for a long time, producing antibiotic-resistant genes that are considered natural and native. But with the use of manufactured antibiotics for humans and animals all over the world, we've seen rapid evolution of resistant genes. We found both native and evolved antibiotic-resistant genes in the Arctic. The concern is that with resistance spreading on this scale, we may be approaching a post-antibiotic era where none of our antibiotics work because the pathogens we're trying to fight have picked up resistant genes via evolution or lateral transfer."
Roberts said the team's findings show the importance of more careful stewardship of antibiotic use and the need for better treatment of wastewater around the world.
"Our human and animal use of antibiotics can have impacts that are beyond ourselves and beyond our local communities -- they are global," she said. "It's really important for us to start thinking of water system management and antibiotics use in ways that are global -- and to start reducing and controlling some of the spread that is clearly not controlled at the moment."
Source: UNIVERSITY OF KANSAS

### Healthmark Offers the Magic Touch
Healthmark has announced the addition of the Magic Touch Magnifier to their Optical Inspection line.
Designed for detailed inspection, the 3.75 x 3.75 x 1.8 Inch Magic Touch has a magnification of 3x and weighs 0.45 lbs. Equipped with three LED lights, the Magic Touch magnifier is a touch activated unit that features an on/off switch for uninterrupted lighting and twist-action focus that allows the user to zoom-in for greater detail. The magnifier includes two CR2016 batteries, a zip case and a microfiber lens cloth to help protect the glass lens from dust, debris and scratching. Visit www.hmark.com for more information.

### Pop-Up Tray Corners
Healthmark Industries has announced the addition of Pop-Up Corner Card to its Sterilization packaging product line. Designed to protect wrapped trays from punctures or tears caused by sharp corners or feet, the 4 x 4 x 2 In. Pop-Up Corner Card simply pops up for easy assembly and fits most trays or baskets. Manufactured from a white rigid paper carton, the Pop-Up Corner Card is heat resistant up to 275˚ F.  www.hmark.com
 

### Support Yourself with The Adjustable Back Brace with Thermo-Pad
Healthmark has announced that they have added the Adjustable Back Brace with Thermo-Pad to its Personal Protection Equipment accessory product line. Designed to provide lower-back support for healthcare professionals on the move, the Adjustable Back Brace with Thermo-Pad helps relieve discomfort by stabilizing the sacrum and lower spine.
Manufactured from a mixture of polyester, nylon and spandex, the back brace is equipped with a removable Thermo Pad that retains body heat in order to provide warmth for aching muscles, joints, tendons and discs. The back brace is made with a reinforced back panel that has eight flexible support stays that shape to the users back while providing lumbar support, elastic side panels with contact closure and adjustable to fit hips from 28 to 50 inches (71.1 – 127 cm).
Visit www.hmark.com for more information.

### New Arm Sleeve
Healthmark Industries has announced that they added the new Arm Sleeve to its Personal Protection Equipment accessory product line.
AORN guidelines state that arms must be covered when preparing and packaging sterile items in the clean assembly area of sterile processing, which is why Healthmark developed the arm sleeves for healthcare professionals working within the sterilization department. Designed as an alternative to the traditional long-sleeved scrub top or jacket, the machine washable arm sleeves are a one-size that fits a bicep of 10-14 inches and are made from a fast drying and moisture wicking polyester material, featuring an elastic gripper to prevent the sleeve from sliding down the user’s arm. Available in blue, green and pink solid colors.
Visit www.hmark.com for more information.

### Boston Scientific receives FDA clearance for single-use duodenoscope, EXALT Model D
Boston Scientific Corporation has announced U.S. Food and Drug Administration (FDA) 510(k) clearance of the EXALT Model D Single-Use Duodenoscope for use in endoscopic retrograde cholangiopancreatography (ERCP) procedures. The EXALT Model D Duodenoscope is an FDA-cleared single-use (disposable) duodenoscope that was granted Breakthrough Device Designation from the FDA to ensure patients and healthcare providers have timely access to this device.
The device has been developed as an alternative to reusable duodenoscopes, eliminating the need for duodenoscope reprocessing and repairs, and allowing physicians to use a new, sterile device for every procedure. The EXALT Model D Duodenoscope builds on the familiar design of standard reusable duodenoscopes so that physicians experience a minimal learning curve when adopting this technology.
Every year, more than 1.5 million ERCPs are performed worldwide using duodenoscopes to diagnose and treat various pancreatic and biliary conditions.
Reusable duodenoscopes are put through a rigorous disinfection process between uses in different patients and the vast majority of procedures with these devices are carried out safely and effectively; however, there have been a small number of cases in which infections have been transmitted between patients via contaminated devices, despite adherence to established protocols. As a result, the FDA has been working with duodenoscope manufacturers, medical societies, physicians and other stakeholders to address this concern.
The FDA recently issued a recommendation that healthcare providers transition to duodenoscopes with disposable components or fully disposable devices, when they are available, and held an advisory committee meeting to discuss this process and other issues related to reducing infection transmission by reusable duodenoscopes.
The FDA Breakthrough Devices Program is intended to help patients receive timely access to breakthrough technologies that have the potential to provide more effective treatment or diagnosis for life-threatening or irreversibly debilitating diseases or conditions.
Boston Scientific voluntarily conducted a consecutive case series of the EXALT Model D Duodenoscope and found that expert endoscopists were able to complete ERCPs across a wide range of complexity using the single-use duodenoscope.
The company plans to commence a limited market release of the device in the U.S. during the first quarter of 2020.
 
 

### Study: Bloating Is Common Among Americans
Nearly one in seven Americans experience bloating on a weekly basis, and most aren’t seeking professional care for it, according to a study led by Cedars-Sinai investigators, published recently in Clinical Gastroenterology and Hepatology.
Even though bloating is a common symptom, some patients may not bring it up with their doctors, said Janice Oh, MD, a resident physician within the Division of General Internal Medicine Division at Cedars-Sinai, and first author of the study. "It’s important that people feel comfortable discussing bloating because it could be a symptom of a serious condition and there are treatments available," Oh said.
Bloating can make people feel swollen or tight in the abdomen. It may occur when a person’s gastrointestinal tract fills with air or gas and can sometimes be the result of diet or an underlying condition, such as irritable bowel syndrome, carbohydrate enzyme deficiency or chronic constipation.
To understand the scope of bloating in the United States, the authors emailed a survey to nearly 90,000 people. Of the 88,795 people who completed the survey from May through June 2020, 12,324 (13.9%) reported bloating in the past seven days.
"To our knowledge, this is among the largest studies of bloating in the U.S.," said Brennan Spiegel, MD, MSHS, director of Health Services Research at Cedars-Sinai and senior author of the study. "Anecdotally, we often hear about bloating in the clinic, but this study adds concrete evidence to describe how commonly it occurs and what other conditions it’s associated with."
Of the people who reported experiencing bloating, about 58.5% said they have never sought care for their symptoms.
Some of the reasons they gave for not seeking care were that the bloating resolved on its own (32.5%), it wasn’t bothersome (29.9%), they were able to manage it with over-the-counter medications or lifestyle changes (20.8%), they didn’t have health insurance (10.2%) or time to go to the doctor (9%), or they weren’t comfortable discussing bloating with a healthcare provider (8.5%). Women were more than twice as likely as men to report bloating.
"Other studies have also found that women report more bloating than men, and researchers have proposed various hypotheses for why this may be occurring," Oh explained. "These include hormonal, metabolic, psychosocial, lifestyle and dietary differences between men and women."
Latinos and people under the age of 60 were also more likely to report bloating within the past seven days, as were people with medical conditions such as such as irritable bowel syndrome, chronic constipation, and ulcerative colitis. People with related gastrointestinal symptoms, such as abdominal pain and excess gas, were also more likely to experience bloating.
"Bloating can often be managed effectively with various medications, such as gut-directed antibiotics or treatments that affect serotonin levels in the gut,” Oh said. “There is also evidence that lifestyle changes can help, including exercise, such as core strengthening, as well as dietary changes, but it requires discussion with a healthcare provider about what might be causing the bloating.”

### Right combination of diet and bacteria limits cancer progression
The diet of a person can have significant effects on the gut microbiome, i.e. the populations of microorganisms such as bacteria which live in the human gut. It is well recognized that dietary habits through complex metabolic interactions contribute to cancer prevention. More specifically, diets rich in fiber reduce the risk of developing specific cancers such as colorectal cancer. Although such diets are an effective means of cancer prevention, their possible roles in cancer progression and treatment remains poorly understood.
A team of scientists from the Luxembourg Centre for Systems Biomedicine (LCSB) and the Life Sciences Research Unit (LSRU) at the University of Luxembourg has found that a combination of prebiotics, such as dietary fiber, and probiotics reduces the expression of pro-carcinogenic and drug resistance genes. The combination leads to metabolic changes that affect the growth of cancer cells and may help treat diseases such as colorectal cancer.
In order to study diet-microbiome-host interactions, the biologists worked with HuMiX ("Human-Microbial X(cross)-talk") a unique in vitro model of the gut ("gut-on-a-chip") which allows the cultivation of human intestinal cells together with bacteria under representative conditions. In this study, they investigated the effects of dietary regimens and a specific probiotic on colorectal cancer cells.
In contrast to individual fiber-rich or probiotic treatments, it was only the combination of fibre and probiotics that led to the observed beneficial effects. Together with their collaborators, the researchers integrated a computer-based metabolic model of the interactions between diet, host, and microbiome.
They identified the effects of the combined treatment: the downregulation of genes associated with colorectal cancer and drug-resistance, as well as the attenuation of self-renewal capacity of the cancer cells. Importantly, through careful molecular analyses, they also identified the cocktail of molecules produced by the combination, providing a mechanistic basis for the observed beneficial effects.
"Currently, cancer patients are not provided with evidence-based personalized dietary interventions during chemotherapy treatment. Our results provide support for exploiting the food-microbiome interactions as a supportive therapeutic approach in anti-cancer therapy," explained Dr. Kacy Greenhalgh, post-doc within the Eco-Systems Biology group at LCSB and the lead author of the study.
"I hope that our results will reach patients and medical practitioners in their respective fields and that in the future more effort is put in including personalized dietary recommendations into cancer treatment plans."
"This is especially the case in CRC, where the microbiome has increasingly gained importance over the last couple of years. A deeper understanding of the microbiome-host interaction could lead to new therapeutic strategies for CRC patients," added Dr. Elisabeth Letellier, principal investigator within the Molecular Disease Mechanisms Group at LSRU.
The research project was successfully carried out thanks to the collaborative effort of different groups at the University of Luxembourg.
"Deciphering the complex host-diet-microbiome interactions and their effect on health and disease states requires the concerted effort of experts from different fields. The interdisciplinary approach was crucial for understanding the very complex molecular processes underlying the observed beneficial biological effects," said associate professor Paul Wilmes, head of the Eco-Systems Biology group at LCSB and senior author of the study.
Source: University of Luxembourg

### New findings on gut microbiome's interactions with GI diseases
A study from the Texas A&M College of Veterinary Medicine & Biomedical Sciences (CVM) offers new insight on how the gut bacteria of dogs interact with a healthy vs. unhealthy GI tract, which could contribute to the development of new therapies for GI diseases in both dogs and humans.
In a study published on Oct. 31 in PLOS ONE, Amanda Blake, a doctoral student with the CVM's Gastrointestinal Laboratory, measured the levels of bacterial metabolic products--fecal lactate and secondary bile acids (BA)--in the fecal matter of dogs with different gastrointestinal (GI) conditions.
Fecal lactate and secondary BA are both substances made by bacteria, and the concentrations at which they are present in fecal matter can inform researchers about the activity of bacteria in the GI tract. The different levels of these substances in a diseased host vs. a healthy host can inform researchers of how GI bacteria act in diseased vs healthy environments, as well as how GI bacteria interact with different diseases.
In her study, Blake found higher levels of lactate and lower levels of secondary BA in the feces of dogs with chronic enteropathy (CE) and dogs with exocrine pancreatic insufficiency (EPI). This is noteworthy since, although these two diseases have different symptoms and causes of disease, the bacterial outputs of their gut microbiota appear to be similar.
"The goal was to look at the bacteria and then also products that the bacteria make. These metabolites, which are lactate and secondary bile acids, reveal similarities across GI diseases that are very different physiologically," Blake said.
These findings can help the community better understand interactions between GI microbiota and disease.
By focusing on the metabolic products of an affected animal, Blake's research is unique in that it accounts for not only the types of bacteria present, but also how these bacteria are interacting with their environment. This is important because the same species of bacteria can produce different products dependent on the health of their environment. A particular species of bacteria in a healthy animal might produce a different chemical than it would in a host with a GI disease.
"If we can find ways that the microbiota interacts with the host and we can compare between health and disease states, then maybe we can alter some of those interactions in disease to make the microbiota healthy and then hopefully make the individual healthy in the end," Blake said.
Currently, treatments for many GI afflictions are non-specific, which might be of more harm than help for the animal. Better understanding the GI microbiome would allow researchers to develop more targeted treatment options.
"Sometimes the inconvenience of a symptom like diarrhea leads to veterinarians to throw everything at the dog: the antibiotics, the steroids. Give it everything, and hopefully one of them will make it stop," Blake said. "We're finding more and more that giving dogs these medications unnecessarily can actually change their microbiota for the worse."
These findings could also be relevant to treating similar GI conditions in human patients.
"Humans also get exocrine pancreatic insufficiency, and chronic enteropathy in dogs is similar to inflammatory bowel disease (IBD) in humans," Blake said. "A lot of people know what IBD is for human medicine, or Crohn's disease. The same findings could be applied to humans with those GI diseases."
Blake emphasizes that an open view on the functions of different species of bacteria is best, and that researchers should be hesitant about labeling certain species as definitively helpful or harmful.
"It's not good guys and bad guys for the microbiota," Blake said. "We need to pay attention to a combination of factors, such as their environment, the metabolic products that they're making, and the individual patient to better understand the role of microbiota in disease."
Source: TEXAS A&M UNIVERSITY

### Fungal invasion of pancreas creates cancer risk
Certain fungi move from the gut to the pancreas, expand their population more than a thousand-fold, and encourage pancreatic cancer growth, a new study finds.
Published online in Nature, the study is the first to offer strong evidence that the mycobiome—the local mix of fungal species in the pancreas—can trigger changes that turn normal cells into pancreatic ductal adenocarcinoma (PDA). This form of cancer is usually fatal within two years.
Conducted in mice and in people with pancreatic cancer, the study found that fungal species travel into the pancreas up the pancreatic duct, a tube through which digestive juices drain in the opposite direction into the intestines. The study authors say this exchange results in abnormal fungal populations in both the gut and pancreas, in the presence of PDA.
Led by researchers from NYU School of Medicine and NYU College of Dentistry, the study also found that treating mice with a potent antifungal drug reduced their PDA tumor weight by 20 to 40 percent over 30 weeks.
“While past studies from our group have shown that bacteria travel from the gut to the pancreas, our new study is the first to confirm that fungi too make that trip, and that related fungal population changes promote tumor inception and growth,” said senior study co-author George Miller, MD, co-leader of the Tumor Immunology Research Program at Perlmutter Cancer Center, the H. Leon Pachter, MD, Professor of Surgery in the Department of Surgery, and professor in the Department of Cell Biology at NYU Langone Health.
While viruses, bacteria, and parasites are recognized by the American Cancer Society as causal factors in the disease, say the study authors, no previous study had linked fungi to pancreatic cancer.
Study details
To determine whether the mycobiome is reprogrammed as normal cells become cancerous (oncogenesis), the team performed analyses over 30 weeks of fecal samples from mice with and without pancreatic cancer. Researchers used genomic and statistical techniques to identify and count the fungal species present. They also attached glowing proteins to fungi to track their migrations through the gut and pancreas.
By the end of the study period, the researchers observed significant differences in the size and composition of the fungal population in the cancerous pancreas when compared to the healthy organ. The largest population increase in both mice and in human tissues was seen in the genus Malassezia, which includes 14 species. The team also detected abnormally higher numbers in the genera Parastagonospora, Saccharomyces, and Septoriella.
“We have long known that Malassezia fungi—generally found on the skin and scalp—are responsible for dandruff and some forms of eczema, but recent studies have also linked them to skin and colorectal cancer,” said senior co-author Deepak Saxena, PhD, associate professor in the Department of Surgery and professor of basic science and craniofacial biology at NYU College of Dentistry. “Our new findings add evidence that Malassezia is abundant in pancreatic tumors as well.”
To test the effect of changing fungal populations on cancer growth, the team treated the mice with amphotericin B, a strong, wide-spectrum antifungal drug. Along with reducing tumor weight, antifungal treatment also reduced the occurrence of ductal dysplasia, an early cellular step toward pancreatic cancer, by 20 to 30 percent.
“Fungal ablation also strengthened the anti-cancer effect of a standard chemotherapy, gemcitabine, by 15 to 25 percent,” said co-first author Berk Aykut, MD, a postdoctoral fellow in Miller’s lab.
After the pancreases of the mice had been mostly cleared of fungi by drug treatment, the team then examined the effect on cancer growth if only certain species were allowed to repopulate the organ. They found that cancer grew 20 percent faster in the pancreases of mice repopulated with Malassezia—but not in the presence of other oft-occurring fungal species.
The study results argue that fungi increase cancer risk by activating an ancient, first-responder part of the immune system, the complement cascade. Such mechanisms fight infections, but also trigger the healing process (cell growth) as infections wane. Along these lines, complement has been shown by past studies to encourage aggressive tissue growth (cancer) when combined with genetic flaws.
“Moving forward, one goal for our team is to determine which species are most relevant to cancer, as doing so could guide future attempts to slow tumor growth with targeted antifungal medications, and to avert side effects,” said co-first author Smruti Pushalkar, PhD, a research scientist at NYU College of Dentistry.
Source: NYU LANGONE HEALTH

### New study sheds light on IBD patients with COVID-19
In an upcoming study to be published in Gastroenterology, scientists at the Icahn School of Medicine at Mount Sinai and the University of North Carolina School of Medicine describe the clinical course of COVID-19 and risk factors for poor outcomes in a large cohort of IBD patients assembled through an international registry.
When the epidemic of COVID-19 began to spread across the nation, the scientists came together to create an international registry of individuals who have inflammatory bowel disease (IBD) and COVID-19. The registry, Surveillance Epidemiology of Coronavirus Under Research Exclusion for Inflammatory Bowel Disease (SECURE-IBD), as of now consists of 528 patients from 33 nations.
"We created the registry to better define the clinical course of COVID-19 in the IBD patient population and assess the relationship between demographics, clinical features, and IBD therapies on COVID-19 outcomes," said Erica Brenner, MD, Pediatric Gastroenterology Fellow, UNC Children's Hospital, study co-author.
The authors conclude that advancing age, comorbidities, and corticosteroids are linked to severe COVID-19 in IBD patients, but a causal relationship cannot be established. Interestingly, TNF antagonists do not seem to be linked to severe COVID-19."One of our key takeaways for the IBD patient population is that it will be important to maintain remission with steroid-sparing therapies during this pandemic."
Our discovery that TNF antagonist therapy is not linked to severe COVID-19 is reassuring news in the context of the high number of patients who need this therapy, presently the most frequently prescribed biologic therapy for IBD patients," said study co-author, Ryan Ungaro, MD, Assistant Professor, Icahn School of Medicine at Mount Sinai and a gastroenterologist with Mount Sinai Hospital's Feinstein IBD Center.
Source: University of North Carolina

### A self-cleaning surface that repels even the deadliest superbugs
A team of researchers at McMaster University has developed a self-cleaning surface that can repel all forms of bacteria, preventing the transfer of antibiotic-resistant superbugs and other dangerous bacteria in settings ranging from hospitals to kitchens.
The new plastic surface -- a treated form of conventional transparent wrap - can be shrink-wrapped onto door handles, railings, IV stands and other surfaces that can be magnets for bacteria such as MRSA and C. difficile.
The treated material is also ideal for food packaging, where it could stop the accidental transfer of bacteria such as E. coli, Salmonella and listeria from raw chicken, meat and other foods, as described in a paper published today by the journal ACS Nano.
The research was led by engineers Leyla Soleymani and Tohid Didar, who collaborated with colleagues from McMaster's Institute for Infectious Disease Research and the McMaster-based Canadian Center for Electron Microscopy.
Inspired by the water-repellent lotus leaf, the new surface works through a combination of nano-scale surface engineering and chemistry. The surface is textured with microscopic wrinkles that exclude all external molecules. A drop of water or blood, for example, simply bounces away when it lands on the surface. The same is true for bacteria.
"We're structurally tuning that plastic," said Soleymani, an engineering physicist. "This material gives us something that can be applied to all kinds of things."
The surface is also treated chemically to further enhance its repellent properties, resulting in a barrier that is flexible, durable and inexpensive to reproduce.
"We can see this technology being used in all kinds of institutional and domestic settings," Didar said. "As the world confronts the crisis of anti-microbial resistance, we hope it will become an important part of the anti-bacterial toolbox."
The researchers tested the material using two of the most troubling forms of antibiotic-resistant bacteria: MRSA and Pseudomonas, with the collaboration of Eric Brown of McMaster's Institute for Infectious Disease Research.
Engineer Kathryn Grandfield helped the team verify the effectiveness of the surface by capturing electron microscope images showing that virtually no bacteria could transfer to the new surface.
The researchers are hoping to work with a commercial partner to develop commercial applications for the wrap.
Source: McMaster University

### LED 4X Magnifier
Healthmark Industries is pleased to announce the the LED 4x Magnifier to its ProSys™ Optical Inspection product line.
Visual inspection of items can be challenging, which is why the LED 4x Magnifier has been specifically designed. Equipped with a 72mm diameter lens for up close visual inspection for potential damage and residual soil after cleaning. The lightweight 85mm x 85mm x 60mm magnifier comes with four white LED lights featuring three levels of brightness, 4x the magnification for easy and thorough inspection, including as directed for enhanced visual inspection of certain robotic instrumentation.
Visit www.hmark.com or call 800-521-6224 for more information.

### An Elusive Disease: Kicking Gastric Cancer in the Gut
By EndoPro Staff
Helen Shipstad thought she had an ulcer.
The woman from Derbyshire, England said in an interview with the Stomach Cancer Awareness Network, “I started getting heartburn, and burning, and just discomfort.” Those symptoms were appearing in February of 2021.
When over-the-counter remedies didn’t help, she scheduled an appointment with a GI specialist. To Shipstad’s surprise, an endoscopy and CT scan revealed not only an ulcer, but also Stage 2 gastric cancer. “It was just a whirlwind after that,” she said.
In the medical industry, cancer is the elephant in the room. It lingers, often unspoken, in many patient conversations about “those weird symptoms I’ve been having” or a doctor’s solemn pronouncement that, “We need to discuss your test results.”
As medical professionals know, cancer isn’t just one disease, and it can start anywhere in the body. According to the American Cancer Society, tumor-related cancers are found in places such as the breast, lungs, prostate or colon. Hematologic cancers are found in the blood cells, and manifest as leukemia, lymphoma or multiple myeloma. What’s worse, cancer can metastasize: infected cells break loose from the original tumor and settle elsewhere in the body, and the proliferation process starts all over again.
Gastric cancer—also known as stomach cancer—starts like most other strains of the disease: a proliferation of cells grows out of control, like some kind of runaway horror film, “Cells Gone Wild.” But there’s nothing even remotely humorous about it—by any stretch of the imagination—that’s for sure. The culprit lies in the cells’ genes: disease development can arise from an inherited genetic flaw, environmental influences, or lifestyle habits. Unfortunately, researchers often don’t know exactly what flips the switch.
In Shipstad’s case, it was a prior Helicobacter pylori infection—innocent enough in itself, but it kicked her up the risk ladder for gastric cancer. According to Wroblewski, et al., H. pylori is found in fully half of the world’s population, and the chronic inflammation it causes wreaks so much havoc that it’s now known as the strongest risk factor for gastric cancer. One of the big problems with H. pylori is that the immune system is incapable of destroying it without help. A Gram negative bacterial pathogen, H. pylori is as comfortable in the harsh, inhospitable environment of the gut as we are in a backyard swimming pool.
The good news about gastric cancer is that it tends to develop slowly. Indeed, it can take years. The bad news is, these cellular changes often don’t cause symptoms, so the disease can easily be overlooked. Liu and Deng call gastric cancer “an important global health problem due to its overall high prevalence and high mortality rate.”
Symptoms
While symptoms can be elusive, they may include dyspepsia and reflux. There may also be signs that “could indicate advanced disease, such as dysphagia, weight loss, gastrointestinal bleeding, anemia, and emesis,” according to a review article titled “Current Treatment and Recent Progress in Gastric Cancer,” which ran in a January 2021 issue of ACS Journals (from the American Cancer Society).
According to the Mayo Clinic, possible symptoms are as follows:
 	trouble swallowing
 	belly pain
 	feeling bloated after eating
 	feeling full after eating small amounts of food
 	not feeling hungry
 	heartburn
 	indigestion
 	nausea
 	vomiting
 	losing weight without trying
 	fatigue
 	stools that look black
Risk Factors
Age and Gender: Men over 60 are at higher risk.
Diet: Foods high in salt or nitrosamines (a preservative found in smoked meats)
Family History: Genetics play a part in GC risk.
Smoking: Small amounts of toxins are swallowed during smoking.
Medical Conditions: Pernicious anemia, atrophic gastritis, helicobacter pylori infections, and Type A blood have all been associated with an increased risk for gastric cancer.
According to World Cancer Research Fund International, additional risk can include chemical exposure, drinking too much alcohol, and being overweight or obese. Grilled or barbecued meat and fish may also be a culprit, as well as consuming little or no fruit. Consumption of citrus in particular may decrease the risk of stomach cardia cancer, the World Cancer Research Fund International posits.
Early screening can be helpful in populations where gastric cancer is prevalent, as well as in high-risk individuals, “including older adults with chronic gastric atrophy or pernicious anemia and patients with gastric polyps, partial gastrectomy, familial adenomatous polyposis, and hereditary non-polyp colon cancer,” write Liu and Deng.
Depending on where in the stomach the cancer starts, treatment can vary. Most often, gastric cancer is found in the stomach’s mucosa, manifesting as an adenocarcinoma. If the patient has an intestinal adenocarcinoma, targeted drug therapy may be an effective treatment. More challenging is the diffuse type of adenocarcinoma, which spreads quickly and is harder to treat.
Less common types of cancer include gastrointestinal stromal tumors, or GISTs; neuroendocrine tumors (NETs); or lymphomas. The rarest types of gastric cancer are squamous cell carcinomas, small cell carcinomas, and leiomyocarcomas.
Global Impact
Worldwide, gastric/stomach cancer is the fifth-most-common cancer. Countries with the highest rate of gastric cancer are Mongolia, Japan, South Korea, Tajikistan and China, cites the World Cancer Research Fund International.
According to the nonprofit Debbie’s Dream Foundation: Curing Stomach Cancer, “Each year nearly 950,000 people worldwide are diagnosed with stomach cancer, and approximately 700,000 die of the disease. Approximately 28,000 Americans will be diagnosed with stomach cancer each year and over 11,000 will die within a year.” A theory presented on the DDF website for why certain countries have a far higher rate of gastric cancer is that the residents of those countries eat a diet heavy in smoked, salted and pickled foods.
Treatments and Procedures
As the sources and types of cancer differ, so do the treatments. In a 2021 review, Puhr and Ilhan-Mutlu itemized advanced and innovative therapies that show great promise in helping those with advanced gastric tumors. They wrote, “... a major issue concerning immunotherapy is that only a subset of patients achieve responses. Thus, the identification of underlying mechanisms for primary resistance to immunotherapy are of major concern.”
Puhr and Ilhan-Mutlu concluded, “Despite the improvement of modern cancer medicine including immunotherapies and targeted therapies, new therapeutic approaches seem to be [efficient] in only specific subgroups of patients. To improve patient outcome with these new treatment options, it is of highest importance to define these subgroups more accurately. The evaluation and implementation of new biomarkers seems to be the key for adequate patient selection leading to high treatment efficacy.”
According to the aforementioned ACS Journals article, the peritoneum may be an effective target for novel therapeutic approaches since it is “the most common site of metastatic disease at diagnosis but also the most common site of recurrence after potentially curative surgery.” The authors continue, “Existing systemic chemotherapy has been shown to improve survival for peritoneal disease, but only at a median of four months according to population-based studies. There has been some enthusiasm for applying heated intraperitoneal chemotherapy (HIPEC) in patients with gastric cancer based on the improved survival in peritoneal disease from other primary sites, such as appendiceal mucinous tumors, ovarian cancer, and mesothelioma.”
In Shipstad’s case, her treatment plan started with six rounds of chemotherapy, two weeks apart, for three months. She underwent a partial gastrectomy and additional chemotherapy, and subsequent pathology indicated that her tumor had shrunk to Stage 1.
These days Shipstad, who now lives in Southern California, is proactive about her health, insisting on quarterly routine scans and an endoscopy every nine months to ensure the cancer hasn’t spread.
“I just think when people have symptoms, it should be taken seriously,” she said. “Because a lot of the time, with the GI tract, there are so many things going on. I never thought it would happen to me. I was told, ‘Oh, you’re too young to have cancer.’ Doctors need to take it more seriously, because as we know, a lot of people are diagnosed when it’s too late. If I had left it another year, I might not be here.”
Debbie’s Dream Foundation: A Resource for Gastric-Cancer Patients and Caregivers
Nonprofit advocacy can go a long way in supplementing medical industry efforts. An example is the nonprofit organization “Debbie’s Dream Foundation: Curing Stomach Cancer,” which is based in Fort Lauderdale, Florida. The nonprofit aims to raise awareness about stomach cancer, to advance research funding, and provide education and support internationally to patients, families, and caregivers. DDF’s main goal is to “make the cure for stomach cancer a reality.”
According to the DDF website, “Our vision is that stomach cancer will no longer be fatal. If not curable, it will be a manageable disease.” Further DDF beliefs on its website are as follows:
 	The concerns and needs of patients must always be front and center with everything we do.
 	Patients deserve the latest knowledge about their disease, treatment options and available support.
 	Doctors must be knowledgeable about the disease, the need to consider it as a diagnosis, the latest treatment options, and the sources of support available to patients, their families and caregivers.
 	We have a responsibility to be transparent to our donors and the community at large.
 	We have a responsibility to remain independent of outside influences that may potentially be biased.
 	Working in collaboration with other nonprofits, businesses, government agencies, scientists and others enhances what we can do.
 	Supporting collaboration within the scientific community will help us achieve our mission and vision more quickly, thus saving lives.
 	Because research holds the key to disease management and the cure, funding is essential.
 	Capturing the imagination and commitment of young scientists early in their careers will result in more focused attention to this disease.
 	Awareness building and advocacy are critical to combating this disease.
 	We as a board must stay educated in order to be as effective as possible and provide valuable direction
The website is a wealth of information and resources for caregivers and for caregivers to recommend to patients. For instance, there is a patient helpline, and a patient resource education program, part of which can include patients being assigned to a mentor. Patients can also join a stomach cancer support community or sign up for clinical trials.
Another benefit medical professionals can recommend is the Dream Makers Miracle Fund for stomach cancer patients and families.
“The initiative is part of our patient resource education program and aims to spread joy within the stomach cancer community by providing patients and families with bucket-list-inspired experiences,” according to the website. The program has made many wishes come true. For example, one woman with gastric cancer was given the opportunity to swim with dolphins, a male patient went skydiving, and several families of patients have received dream vacations. There are also scholarship programs available.
Other sections of the site include information about stomach cancer risk factors, symptoms, screening, early detection, diagnosis, staging, choosing a treatment facility, treatments, chemotherapy, nutrition, surgery, radiation, molecular testing, genetics, and the latest in updates regarding diagnosis and treatment.
Medical professionals and research peers may be interested in the section about research grants. The Debbie’s Dream Foundation has given more than $1,450,000 in research grants, and interested parties can apply through the DDF website. For more information, visit www.debbiesdream.org.

### PPE 101: Keep Your Staff Safe From Infections
By Erica Smith, MBA, and John Sullivan
The sterile processing department (SPD) and healthcare professionals responsible for cleaning, reprocessing, and sterilizing instruments to treat patients, play a daily but vital role in the health care system. Keeping patients healthy and reducing the risk of healthcare-acquired infections (HAIs) is the main goal.
While practitioners are taught to carefully follow the instructions for use (IFUs) when cleaning anything from a simple set of scissors to a complex endoscope, technicians should not forget about minimizing the risk of infection for themselves. This is a vital component of the infection prevention process. By taking the following steps, healthcare professionals can help keep everyone healthy and safe from infections.
Clothing
Any item of clothing worn while cleaning or reprocessing instruments should never be worn outside of a facility, and facilities should provide the basic clothing, as well as an area to change, before and after a shift. Individuals cleaning instruments or working in the SPD should always wear long sleeves. If clothing becomes soiled at any time during the shift, change immediately as part of the infection control process. Clothing should also include non-skid shoes and should only be worn in the facility.
Head Coverings
In areas in which instruments are being cleaned, individuals should wear head coverings and a disposable bouffant cap. If a reusable head covering is used, be sure to clean it daily and keep it covered by a separate, single-use disposable head covering that is changed between procedures. If the tech has a beard, a beard covering must be worn.
Face Masks
An important part of personal protective equipment (PPE) is the face mask. A minimum American Society for Testing and Materials–rating of level 2 should be worn, and the outer layer of the mask should be fluid resistant. Ensure the face mask fits over the nose and mouth and extends around the chin. There should be minimal gaps to ensure full protection. Also change face masks frequently throughout the day.
Along with face masks, proper eyewear/goggles should be worn, and covered with a face shield that extends down past the chin for best protection.
The person reprocessing the instruments should wear a fluid-resistant apron, gown or jumpsuit that is approved to be worn in a decontamination area.
Gloves
Gloves specifically approved for use in healthcare decontamination areas must be worn. Double gloving should also be part of the standard process. When choosing a glove, consider the following:
 	degradation rating
 	breakthrough time
 	permeation rate
The outer glove should be designed specifically for instrument reprocessing. These gloves are thicker, designed to help protect a tech’s hand from sharp instrument components. They also have much longer cuffs that extend over a tech’s sleeves to keep fluids from penetrating the glove or sleeve.
Ensure the gloves are compatible with the chemicals used throughout the SPD area. Following the manufacturer’s IFU for both the gloves and chemicals can help ensure the gloves will stay intact throughout the decontamination process.
Donning PPE
When donning PPE, follow these steps:
 	Gown
 	Fully cover the body from neck to knees. Wrap the gown around the back.
 	Do not take the shortcut and have the opening in the front of the body, as this opens the possibility for contaminated material to reach the undergarment of the professional.
 	Mask 
 	Secure the mask around the face and ears. Ensure the face is covered from the bridge of the nose and around the chin.
 	Form the flexible nose bridge.
 	Ensure there is no gapping around the face.
 	Goggle and Face Shield
 	Place over eyes.
 	Adjust the fit for unobstructed vision.
 	Gloves 
 	Ensure the gloves extend to cover the wrists of the isolation gown.
Doffing PPE
When the instrument/device cleaning has been completed, proper doffing guidelines should be followed as recommended by the Centers for Disease Control and Prevention (CDC). These practices are just as important as the PPE selection itself. When removing PPE, assume that all pieces are contaminated, so take extra care to minimize the risks of touching potentially infectious material. Follow the below steps:
 	Gowns and Gloves
 	Grasp the gown in the front and pull away from the body, touching the outside with only gloved hands.
 	While removing, fold the garment into itself with the outside inward.
 	Dispose of PPE in the proper container.
 	 Goggles and Face Shields
 	With gloves on, remove goggles from the back by lifting the headband and without touching the front of the goggles and/or face shield.
 	If any of the equipment is reusable, place it in the proper bin for reprocessing.
 	 Mask
 	Always consider the face covering to be contaminated. Never touch the front of the mask.
 	Grasp the ties or elastic bands straps and pull carefully off the ear and away from the face.
 	Dispose of the mask properly.
Once all PPE is removed, or if any time during the process hands become contaminated, wash hands immediately using an approved soap or an alcohol-based sanitizer. The CDC has a downloadable reference on proper PPE use, which includes donning and doffing diagrams.
Purchasing PPE
With the onset of COVID-19, new manufacturers of PPE have emerged. With this in mind, it is important to ensure that the PPE a facility uses has approval for the specific application. In some cases, PPE manufacturers may not have gone through testing to have their masks receive a 510K. Be sure to work with a trusted distribution partner to find the best quality PPE products.
Chemicals 
PPE is vital in protecting staff from the chemicals used throughout SPD. These chemicals include presoak/holding solutions, cleaning and disinfecting chemicals, and high-level disinfectants or sterilants. Holding solutions or enzymatic solutions are meant to prevent bioburden from clinging to the instruments. The CDC states that it is necessary to remove any bioburden from instruments in order for proper sterilization (CDC, 2016).
Using presoak/holding solutions immediately after procedures should help ensure bioburden does not stay on the instrument during cleaning. Many presoak/holding solutions use enzymatic chemicals that have an Environmental Protection Agency (EPA) category 2 ranking, which means they could cause serious eye damage or skin irritation. This reiterates the importance of staff consistently wearing the correct PPE throughout the SPD process.
Next is the instrument washing process. These chemicals clean and disinfect the instruments before they undergo the autoclave for sterilization. There are two different methods of cleaning instruments: manual and automated. When staff are manually cleaning instruments, ensure all PPE is worn correctly and intact. Handling instruments manually can increase the chance of a sharps injury if the proper PPE is missing or torn.
Manual vs. Automated Cleaning
Manual cleaning is proper for fragile instruments that cannot be processed in ultrasonic cleaners and instrument washers. Ultrasonic cleaners and instrument washers are great for cleaning instruments with hard crevices. This helps automate the SPD process.
By utilizing automatic cleaning equipment, the risks of sharps injuries can be reduced. While not every instrument can handle being cleaned in this equipment, it is important to utilize at least one, if possible, to help clean crevices of certain instruments. Different chemicals can be used for the cleaning stage. Depending on the active ingredient, they typically have an EPA category 2 and category 3 ranking. Adverse reactions can include eye damage, irritation, and skin corrosion and irritation. Any staff managing these chemicals must ensure they are wearing and using their PPE correctly.
Sterilization 
The last step is the sterilization process. Depending on the type, instruments that can withstand heat and steam can be sterilized in an autoclave. Instruments that cannot withstand heat or steam can be sterilized in low-temperature autoclaves or with a high-level disinfection/sterilant.
Low-temperature options may include ethylene oxide, or hydrogen peroxide plasma gas. High-level disinfectants can use glutaraldehyde, hydrogen peroxide, ortho-phthaldehyde, and other active ingredients. EPA-regulated surface disinfectant chemicals range from a category 1 to category 4 ranking. Category 1 chemicals are highly toxic, while category 4 chemicals are not acutely toxic.
Because of the different hazards that can be encountered during sterilization, it is important to ensure that staff maintain the correct procedures and use the correct PPE. However, even in light of this, the CDC found that nearly 44 percent did not wear their protective gowns, and 9 percent did not wear the correct gloves (CDC, 2018). The CDC also discovered that 17 percent have not received training, and 42 percent claimed their last training was more than 12 months prior (CDC, 2018). The lack of proper use of PPE and training can open the door for accidents or cross-contamination. The lack of training could stem from such challenges as consistent changes in guidelines, lack of staff to train, and training cost.
Despite these challenges, it is imperative to ensure training is completed. Consistent training and accountability will help prevent accidents and cross-contamination. Even when facilities have high turnover or temporary staff, providing consistent training to all current and new staff will help maintain a safer environment.
Depending on the type of pathogen, there could be a high risk of transmission. Training, proper technique, and PPE are there to prevent risk to the staff or other patients. According to Sullivan Healthcare Consulting, it is estimated that due to lack of proper technique, training, and PPE, the United States spends an average of $9.8 billion in treating hospital-acquired infections (HAIs) and surgical site infections (SSIs). With new pathogens continuously discovered, this number could potentially increase due to the transmission rate of the new pathogens. As new pathogens are discovered, techniques and training could change, just as they did with COVID-19. It is important to have the most recent technique guidelines and training implemented into the facility to help prevent the spread of infection.
Conclusion
In a busy department, it can be easy for certain steps to fall to the sidelines. Following instructions for use, using personal protective equipment correctly, and implementing and maintaining appropriate training for staff are key elements to help prevent the spread of disease throughout a facility.
PPE should be used as part of a comprehensive infection control program that follows CDC recommendations and guidelines from the Occupational Safety and Health Act of 1970 (OSHA) requirements, including the Bloodborne Pathogens (29 CFR 1910.1030), PPE (29 CFR 1910.132), and Respiratory Protection (20 CFR 1910.134). 
Great resources are available to help design a PPE program, including ANSI/AAMI ST91 (the American National Standards Institute/the Association for the Advancement of Medical Instrumentation), and through the Society of Gastroenterology Nurses Association, Association of Perioperative Registered Nurses, and Health Sterile Processing Association of Healthcare Central Service Material Management.
We deliver care in a world where new pathogens are discovered constantly. By always following proper technique and maintaining training, facilities will be ready and prepared to help keep everyone safe when new pathogens may be discovered.
Erica Smith, MBA, is a surgical solutions manager at Henry Schein, Inc. She helps guide healthcare professionals in conducting proper infection prevention protocols throughout ambulatory surgery centers. She is completing her doctorate in public health and believes that by helping health care professionals improve their infection prevention processes, communities can receive better care. 
John Sullivan is the director of sales for the Alternate Care Division at Crosstex (a member of the HU-Friedy Group and now part of Steris). Sullivan began his career as the Healthcare Channel Manager for Reckitt Benkiser, the creator of Lysol, and has been involved in sterility assurance for more than 20 years. 
For references, visit www.endopromag.com.
 

### FDA clears GI Scientific’s ScopeSeal single-use disposable endoscopic shield
GI Scientific, LLC, a developer of transformative innovations for gastrointestinal disease, announced that the U.S. Food and Drug Administration (FDA) cleared its ScopeSeal Duodenoscope Protective Device, an endoscopic shield for protecting the distal end of a duodenoscope from contamination during ERCP procedures. ScopeSeal  is a single-use disposable infection control device that preserves duodenoscope optics and other key functionality while sealing the infection prone distal end of the Olympus duodenoscope used in ERCP procedures. ScopeSeal is the only device cleared for human use by the FDA that seals the elevator area of the scope and significantly reduces duodenoscope distal end contamination during use.
More than 700,000 U.S. ERCP procedures, and nearly 2 million global ERCP procedures are performed annually as an important less invasive treatment alternative to invasive surgery for assessing and treating critical liver, pancreas, and gallbladder conditions. These highly beneficial, less invasive procedures rely on reusable duodenoscopes as the central enabling technology for these treatments; however, hard-to-clean recessed areas at the distal end of the scope, especially the recessed elevator area, have been linked to failures to remove biomatter contamination from the scope through scope disinfection and reprocessing efforts, resulting in patient-to-patient cross contamination and multiple drug-resistant infections. Significant infection outbreaks and multiple deaths have been reported from drug-resistant infections linked to contaminated duodenoscopes.
ScopeSeal easily and securely attaches to the distal end of a reusable duodenoscope to two-way protection of the scope--: an "outside in" barrier ndesigned to significantly reduce biomatter soiling of the distal end of the scope during use and "inside out" protection, which seals the elevator area of the scope and provides a sealed passageway allowing instruments to be passed through the duodenoscope into the patient’s GI tract without contacting the elevator area of the scope, according to the manufacturer.
ScopeSeal is cleared for use on the Olympus TJF-Q180V duodenoscope, the duodenoscope used in approximately 85% of U.S. ERCP procedures, and is compatible with instruments used in ERCP up to 10.7 Fr in diameter. ScopeSeal is not a replacement for careful adherence to the important and valuable duodenoscope reprocessing steps and related scope maintenance requirements specified by the reusable duodenoscope manufacturer.
The ScopeSeal infection control technology is a platform applicable to other scopes and indications, including duodenoscopes with non-sealing disposable caps, which the company is evaluating with respect to pursuing additional, future regulatory clearances.
Source: BUSINESS WIRE

### Impacts of low-dose exposure to antibiotics unveiled in zebrafish gut
The study, published this week in the Proceedings of the National Academy of Sciences, applied three-dimensional microscopy to nearly transparent zebrafish to show how weak levels of antibiotics induce structural changes in gut bacterial communities that cause severe drops in the bacterial populations.
"Low levels of antibiotics are often found as environmental contaminants, for example from widespread use in raising livestock," said Raghuveer Parthasarathy, a professor of physics and member of the UO's Institute of Molecular Biology. "It's known that weak antibiotics can dramatically alter the human gut microbiome, but why this happens has been a mystery."
Zebrafish larvae are a good model for tackling the mystery, Parthasarathy said, because they share many anatomical similarities with humans and other vertebrates, and their intestinal microbes can be directly observed.
Doctoral student Brandon H. Schlomann and postdoctoral researcher Travis J. Wiles led the project, in which larvae were observed with 3D microscopy as they were exposed to concentrations of the antibiotic ciprofloxacin at levels comparable to that often found in environmental samples.
The researchers looked separately at zebrafish carrying one of two different bacterial species that are each frequently found in the zebrafish gut. Bacteria of one of the species are motile and fast-swimming. Bacteria of the other species are almost completely aggregated in dense colonies.
In the presence of the antibiotic, both types of bacteria showed dramatic changes in their behavior. The normally motile species became much slower and formed aggregates. The normally aggregated species shifted in structure to form even larger colonies, with less fragmentation.
In both cases, the enhanced aggregation made the bacteria more sensitive to the mechanical contractions of the intestines, leading to increased expulsion from the gut and more than hundred-fold drops in the intestinal populations.
"Our findings," Parthasarathy said, "suggest that because of the physical activity of the intestine, contamination by antibiotics induces much larger changes to the gut microbiome than one would suspect from simply studying bacteria alone. In a sense, the gut amplifies the effects of weak antibiotics."
Based on their observations, the researchers developed a mathematical model of bacterial dynamics in the gut, with predictions for colony sizes that matched experimental data. The model is similar to those of polymer and microparticle growth, showing, the co-authors write, that methods developed in physics can be fruitfully applied to studies of the gut microbiome.
Parthasarathy expects the team's findings to apply to more than zebrafish.
"A wide range of bacteria respond to weak antibiotics by changing their shape and aggregation behaviors," he said. "All vertebrate intestines -- humans' included -- transport food and microbes, and their mechanics drive the motion of bacterial groups. We suspect, therefore, that the things we've discovered are quite general across species, including humans and other animals."
The model, Parthasarathy and colleagues write, provides a framework for evaluating antibiotic perturbations in humans and other animals. The five-member team suggests that the expulsion of live antibiotic-exposed bacteria from animal intestines through the aggregation-based process may be a mechanism for the spread of antibiotic resistance.
Source: UNIVERSITY OF OREGON

### Wassenburg Medical Dry320 Drying Cabinet
Optimum drying process
Endoscopes in our drying cabinets are stored in a vertical hanging position, allowing gravity to facilitate the drying process. Vertical hanging is recommended in endoscope manufacturer's guidelines and is in compliance with the recommendations of the ESGE-ESGENA guideline 939.
Extended storage
Our drying cabinets guarantee a controlled and safe storage preserving the washed and disinfected state of the endoscope for up to 30 days.*
The extended storage period in a conditioned environment allows for more efficiency within the department by having timely access to the endoscopes when they are needed.
Designed to contribute to a safe and controlled treatment of flexible endoscopes. The WASSENBURG® DRY320 is a patented drying system that has been developed to provide ergonomic handling for its users, optimum endoscope positioning, and proven drying efficacy.  Please visit our webpage at www.Wassenburgmedicalinc.com
Wassenburg Medical
144 Railroad Drive
Ivyland, PA 18974
Phone: 215 364 1477

### Fight Colorectal Cancer launches clinical trial finder mobile app in partnership with Flatiron Health
Fight Colorectal Cancer (Fight CRC) has collaborated with Flatiron Health to develop a smartphone application for its Late-Stage, MSS-CRC Clinical Trial Finder. The first-of-its-kind app — now available for both iOS and Android — enables patients with late-stage Microsatellite Stable (MSS) colorectal cancer to research relevant clinical trials via their phone.
The Fight CRC Clinical Trial Finder was the work of stage IV colorectal cancer survivor, Dr. Tom Marsilje, who originally curated MSS-CRC clinical trials into a list using just a spreadsheet. As word of the resource began to spread, Dr. Marsilje expanded the tool to make it easier for patients to search for trials. In 2017, he partnered with Fight CRC and Flatiron Health to further modernize his efforts and reach more patients.
In May 2017, Flatiron Health built a web-based version of the Clinical Trial Finder during one of the company’s quarterly hackathons, a two-day event that provides its employees an opportunity to take on a grassroots side project outside of their daily work. Since May 2017, nearly 14,000 people have utilized the tool, equating to over 24,000 unique searches. The mobile app version of Clinical Trial Finder represents an ongoing effort by the Flatiron team.
“I’m so excited to see this app come to fruition. Empowering patients and improving access to clinical trials will help us continue to move the needle for patients with colorectal cancer,” said Neal Meropol, Vice President of Research Oncology at Flatiron Health and a member of Fight CRC’s Medical Advisory Board.
The trial finder serves patients and their caregivers with a curated list of potential clinical trials for them to subsequently discuss with their medical team. The tool is updated daily with the latest details on new and existing trials and monitored by Maia (Cee Cee) Walker, a volunteer, and clinical trials expert, along with the support of trained Fight CRC research advocates.
“The launch of this app for the Fight CRC Clinical Trial Finder is what Tom always envisioned,” said Fight CRC president Anjee Davis. “We are so grateful to our partners at Flatiron for their tremendous work in bringing this dream of Tom’s to fruition. It will be a game changer for patients and caregivers--delivering the latest in clinical trials to their phones and giving them a sense of control during a time when they so often feel powerless.”
The filtered curation is generated from all potential MSS-CRC patient-enrolling trials and is based on parameters that are most important from the viewpoint of stage IV, MSS-CRC patients. The content is sourced from a publicly available repository of all trials listed on ClinicalTrials.gov, that is maintained by the Clinical Trials Transformation Initiative (CTTI).
To learn more about the Clinical Trial Finder visit http://trialfinder.fightcrc.org/.
Source: Fight Colorectal Cancer

### The Latest in Dress Code and Personal Hygiene for Endoscopy Processing Staff
By Nancy Chobin, RN, AAS, ASCP, CSPM, CFER
Personal dress code and hygiene play an important role in infection prevention of staff and patients. Sometimes, we do not always take the time to ensure compliance, which is unacceptable. To understand this better, let’s look at the recommendations and their importance.
Personal Hygiene 
Good personal hygiene involves keeping all parts of one’s external body clean and healthy. Developing and maintaining good personal hygiene habits is important for an individual’s physical and mental health. It is critical that employees of the GI/endoscopy suite demonstrate good personal hygiene. Individuals with poor personal hygiene provide an ideal environment for the growth of microorganisms, leaving the body vulnerable to infection. Conversely, when an individual maintains good personal hygiene, the body sheds fewer bacteria into the environment, which is important in an area where medical devices are being processed. Reprocessing flexible endoscopes is arduous and requires stamina, so reprocessing technicians should strive to maintain good health by eating a well-balanced diet and getting plenty of sleep.
According to the Centers for Disease Control, good personal hygiene includes body hygiene, frequent hand hygiene and nail hygiene.
Attire 
All personnel entering the processing area should change into clean surgical scrub attire provided by and donned at the facility. Reusable scrub attire should be laundered by a healthcare-accredited laundry (ANSI/AAMI ST65:2008, ANSI/AAMI ST79:2017, ANSI/AAMI ST91:2021, AORN 2021b). This is important to keep the microbial level to a minimum.
Attire should be changed daily or more often as needed (i.e., when wet, grossly soiled, or visibly contaminated with blood or other body fluids). All head and facial hair (except for eyebrows and eyelashes) should be completely covered with a facility-approved head covering. Personnel should remove and discard head coverings whenever they leave the decontamination area. Upon reentry to the area, they should apply a new head covering. Fallout from head and facial hair can contaminate devices after they have been cleaned. Therefore, compliance is recommended.
Shoes worn in the processing area must be clean, have non-skid soles, and be sturdy enough to prevent injury if an item drops on the foot. Open-toed and clog-type shoes should not be permitted because they will not protect the feet from injuries that could occur when items are dropped. Liquid-resistant shoe covers should be worn if there is potential for shoes becoming contaminated and/or soaked with blood or other bodily fluids (29 CFR 1910.1030).
Jewelry (including earrings, necklaces, rings, bracelets, and wristwatches) that cannot be contained within the surgical scrub attire should not be worn in the decontamination, preparation, high-level disinfection, sterilization, or sterile storage areas. Jewelry should not be worn because it is not easily or routinely cleaned on a daily basis. In addition, it can harbor microorganisms, can become dislodged and fall into processed items, and can cause holes in gloves or other barrier protection.
Wristwatches and rings can catch on equipment or instruments, injuring personnel or damaging the item or packaging. Rings can also interfere with effective hand hygiene. One study found a tenfold higher median skin-organism count on the hands of healthcare providers wearing rings (AORN, 2021b). Another found that finger rings increased skin surface bacterial counts; although hand hygiene reduced bacterial counts, there were more bacteria under the rings than on the adjacent skin or on the opposite hand (AORN, 2021b).
Cloth head coverings or long-sleeved jackets should be laundered in the same manner as surgical-scrub attire (i.e., either by designated facility personnel or by a healthcare-accredited laundry service). Home laundering processes cannot be standardized and might not be sufficient to eliminate pathogenic (disease-producing) organisms from scrub attire. The OSHA Bloodborne Pathogens Standard states that if a uniform becomes soiled with blood or body fluids, it must be laundered at the facility; the employee is not permitted to take the uniform home for laundering (29 CFR 1910.1030).
Whether employees should wear cover apparel (e.g., cover gowns, lab coats) when they leave the sterile processing area to travel to other areas of the healthcare facility should be determined by each facility and should comply with state and local regulations. If cover apparel is worn, it should be clean (AORN, 2021b). Employees should change into street clothes when they leave the healthcare facility or when traveling between buildings located on separate campuses. (ANSI/AAMI ST91:2021, AORN, 2021b) .
Personal Protective Equipment (PPE)
Wearing PPE is essential to personnel safety. PPE includes fluid-resistant jumpsuits and gowns, hair coverings, impermeable shoe coverings, surgical masks and face shields, eye protection, and gloves. PPE must not permit blood or other fluids to pass through to the employee’s clothing, skin, mouth, eyes, or mucous membranes under normal working conditions. And of course, PPE must be worn when necessary.
OSHA Regulations: PPE
The OSHA Bloodborne Pathogens Standard (29 CFR 1910.1030) requires employers to identify tasks that might put employees at risk for exposure to blood and/or other body fluids and to take appropriate measures to protect them from exposure. The type of PPE worn by an employee may vary, consistent with the tasks to be performed.
According to OSHA, the selected PPE must “not permit blood or other potentially infectious materials to pass through or reach the employee’s work clothes, street clothes, undergarments, skin, eyes, mouth or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used” (29 CFR 1910.1030(d)(3)(i)).
PPE use is not optional. It is the responsibility of the employer to provide appropriate PPE, ensure that it is used, and document and investigate failure to comply. Designated facility personnel should provide education and training for all employees regarding the appropriate PPE that should be worn for the tasks they perform and the potential health and disciplinary consequences for failure to do so. This training should be documented and routinely verified as part of the departmental competencies. The training should include the correct steps in donning and doffing PPE. 
Recommended PPE 
According to ANSI/AAMI ST91:2021, because of the potential for soaking clothing, splashing, and the aerosolization of fluids and contaminants, and the consequent need to protect employees from exposure to both microorganisms and chemicals, appropriate PPE in the endoscope cleaning area includes the following items:
 	General-purpose utility gloves. Processing personnel should wear a style of glove that prevents contaminated water from contacting skin or personal clothing. General-purpose or higher-level utility gloves that are fitted at the wrist should be used. Gloves that are too short, do not fit tightly at the wrist, or lack cuffs do not provide adequate protection. Likewise, exam gloves should not be used for decontamination. Many glove manufacturers offer decontamination gloves, some of which are 18 inches long.
 	A long-sleeved, impervious (fluid-proof) or fluid-resistant gown or jumpsuit. When there is a possibility that attire can become soaked with blood or other potentially infectious material, a Level 4 gown (as defined by ANSI/AAMI PB70:2012) should be worn.
 	A fluid-resistant face mask and eye protection. PPE worn to protect the eyes from splash and/or splatter may include goggles, full-length face shields, or other devices that prevent exposure from all angles. Face masks provide protection for the mouth and nose.
 	Fluid-protective shoe covers with slip-proof bottoms. Shoe covers are recommended when there is a potential for shoes to become contaminated with blood or other body fluids (OSHA 29 CFR 1910.1030). Shoe covers should be removed before leaving the endoscope reprocessing area.
Reusable gloves, glove liners, aprons, and eye-protection devices should be decontaminated according to the manufacturer’s written IFU after each use. If the integrity of an item has been compromised, it should be discarded.
Personnel should remove torn gloves and thoroughly wash their hands before donning new gloves. After completing processing activities, they should remove PPE and wash their hands. Before handling processed endoscopes, personnel should don clean PPE (ANSI/AAMI ST91).
Before leaving the decontamination area, personnel should remove all PPE and wash their hands, being careful not to contaminate skin or the clothing worn beneath PPE. Designated facility personnel should educate and train employees about how to correctly don and doff PPE and ensure that designated areas and containers for clean and used PPE are provided.
The CDC offers an instructional poster for donning and doffing PPE. Developed during the Ebola outbreak a number of years ago, it continues to be used today. The only PPE not covered in the poster are shoe covers. The poster is available at:
https://www.cdc.gov/hai/pdfs/ppe/ppeposter148.pdf
Summary
The facility/department should have a policy on required dress code and ensure staff compliance. In addition, the policy should be referenced to AAMI and OSHA standards and AORN or SGNA Guidelines. There should also be a policy on the required PPE and since this is a regulation, monitoring staff compliance is critical.
According to the OSHA webpage on penalties, “Any serious violation (which non-compliance with PPE is considered) the potential fine is $15,625 per violation. Employers can be cited for violation of the General Duty Clause if a recognized serious hazard exists in their workplace and the employer does not take reasonable steps to prevent or abate the hazard. The General Duty Clause is used only where there is no standard that applies to the particular hazard. The following elements are necessary to prove a violation of the General Duty Clause: The employer failed to keep the workplace free of a hazard to which employees of that employer were exposed;
 	The hazard was recognized;
 	The hazard was causing or was likely to cause death or serious physical harm; and
 	There was a feasible and useful method to correct the hazard.
Therefore, PPE must be provided, in-serviced in its use and monitored for compliance for employee and patient safety.
Nancy Chobin, RN, AAS, ACSP, CSPM, CFER, is the president and CEO of Sterile Processing University, LLC, of Lebanon, New Jersey. Her company was founded in 1996 and provides SPD and GI consultations, competency assessments, design of sterile processing areas (in hospitals, surgery centers and endoscopy processing areas), on-site training, and online training courses for ambulatory surgery, SPD and endoscopy processing personnel. 
Chobin consults for dental and medical offices where sterilization is performed. She has authored three textbooks and two workbooks, has provided chapters, and served as an editor for other textbooks on sterile processing. Chobin has lectured extensively in the United States; Latin, Central and South America; Mexico; and in Asia and Europe. Chobin has published numerous articles in a variety of professional magazines. 
References
 	Association for the Advancement of Medical Instrumentation. Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities. ANSI/AAMI ST79:2017. Arlington (VA): AAMI, 2017.
 	Association for the Advancement of Medical Instrumentation. Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities. ANSI/AAMI ST79:2017, Amendment 1:2020. Arlington (VA): AAMI, 2020.
 	Association for the Advancement of Medical Instrumentation. Flexible and Semi-Rigid Endoscope Processing in Health Care Facilities. ANSI/AAMI ST91:2021. Arlington (VA): AAMI, 2022.
 	Basics of Flexible Endoscope Reprocessing 3rd Edition, 2022, Sterile Processing University, LLC, Lebanon, NJ.
 	Centers for Disease Control and Prevention. (December 1, 2022). Personal Hygiene. Retrieved from https://www.cdc.gov/hygiene/personal-hygiene/index.html
 	Occupational Safety and Health Administration. (December 20, 2022). OSHA Penalties. Retrieved from https://www.osha.gov/penalties
 	Occupational Safety and Health Administration. (December 18, 2003). Standard Interpretations. Retrieved from https://www.osha.gov/laws-regs/standardinterpretations/2003-12-18-1
 

### Researchers identify seasonal peaks for foodborne infections
Each year, thousands of pounds of food are wasted and billions of dollars in food sales lost because of recalls tied to foodborne infections. Using a newly developed approach, researchers identified seasonal peaks for foodborne infections that could be used to optimize the timing and location of food inspections.
"We rely upon food producers, distributors and retailers to keep food safe in fields, grocery stores and restaurants," said Ryan B. Simpson, doctoral candidate at Tufts University Friedman School of Nutrition Science and Policy. "A lapse in food safety practices during any step in the food delivery and supply chain can jeopardize human health, waste food resources and threaten the national food economy."
Foodborne infections can be caused by a variety of pathogens, such as Listeria, Salmonella and E. coli. A single pathogen can lead to outbreaks that peak in different states at different times. Knowing the patterns for each pathogen and state could be used to design an optimized schedule for food safety inspections.
To characterize the timing and intensity of infection peaks, Simpson and colleagues developed an analysis method that robustly determines which specific pathogens are likely to cause an outbreak at a given time.
Using their new analysis method, the researchers found that although foodborne outbreaks typically peak in July, food recalls are delayed by one to two months, peaking from mid-August through mid-September. These findings were consistent across examined states and pathogens.
Next, the researchers aim to refine their analysis method by exploring specific foods and food groups linked to foodborne outbreaks. They also plan to examine relationships between outbreaks for particular pathogens with food preparation practices and other factors.
"Our future research will provide valuable information that could help refine existing food safety policies while also aiding food producers, distributors and retailers in preventing or mitigating foodborne outbreaks," said Simpson.
Source: American Society for Nutrition

### AORN announces cancellation of the 2020 Global Surgical Conference & Expo in Anaheim
AORN announced yesterday the cancellation of their Global Surgical Conference & Expo in Anaheim March 28 to April 1 over concerns of the novel coronavirus (COVID-19). Their statement reads:
Over the past week, AORN has received many calls from nurses, exhibitors, and others regarding our intention to continue with the conference. Everyone, including AORN, wants a conference that is an outstanding experience and certainly one that assures a safe environment.
AORN takes very seriously its mission to keep healthcare workers and surgical patients safe. Despite everyone's best efforts, we cannot promise a safe environment for nurses, exhibitors, vendors and staff. Therefore, consistent with our values of communication, quality, innovation and collaboration we regret to inform you, AORN Global Surgical Conference & Expo 2020 is cancelled.
Unfortunately, postponement is not an option because of the event size and the limited number of cities able to accommodate us. Neither do we anticipate a near-term solution to contain the spread of COVID-19.
We understand you have many questions regarding your participation at AORN Expo 2020.  We are in this together. We will be in contact with you in the coming days regarding any refunds and/or credits for future services.
We share your disappointment and sincerely thank you for your understanding of this very difficult decision.
AORN is reviewing processes and procedures for any refunds or credits. We appreciate your patience. We will be in touch with all registrants and exhibitors soon.
If you have urgent questions before we are able to contact you, please email: Expo2020Inquiry@aorn.org.

### Healthmark Introduces Two New Cleaning Brushes to its ProSys™ Instrument Care product line
Healthmark Industries is pleased to announce the addition of two new brushes to their ProSys™ Instrument Care product line.
Designed for cleaning instruments prior to further processing, these reusable brushes are manufactured with nylon bristles that adhere to a contoured plastic handle. These brushes are used in conjunction with a suitable cleaning solution that assist healthcare workers in the initial cleaning of items for which brushing to remove contamination is a recommended step in the cleaning process. The “3183-P” is available for purchase in a package of 10 and the “MR001903” is available in a package of 3.
Visit www.hmark.com or call 800-521-6224 for more information.

### Partnership Creates Massive Repository of Gastroenterology Real-World Clinical Data
PALO ALTO, California—Lynx.MD recently announced a partnership with Gastro Health (a U.S. medical group specializing in digestive and liver health) to create an extensive repository of real-world clinical data in the gastroenterology space for research and development of new GI solutions. Gastro Health will use the Lynx platform across its practices to support research and development of GI-specific digital tools to support outstanding medical care.
The partnership will create repositories of structured and unstructured GI-related medical datasets and will provide researchers with the data they need to improve outcomes for gastrointestinal patients globally. The Lynx platform provides advanced firewall algorithms and the application of medical-grade cybersecurity protection protocols, enabling partners to securely use de-identified, real-world data.
Gastro Health maintains full control of what data is anonymized, and when and with whom data is shared. The actual data never leaves Gastro Health’s private cloud environment. Researchers receive secure permissioned access to perform large-scale computations, modeling and analysis within the platform.
“At Gastro Health we understand that harnessing the power of data and modern computing can support the delivery of transformational tools and insights to support clinicians and inform the delivery of the best possible patient care,” said Rich Weissmark, senior vice president of strategic operations at Gastro Health. “We selected Lynx.MD’s medical intelligence platform to achieve efficiencies across our data network and for the possibilities it opens up to safely and securely collaborate with healthcare partners across the continuum of care to provide preventative and predictive medicine.”
The fundamental business model of gastroenterology has changed dramatically in the last few years, according to Dr. John Allen, former chair of the American Gastroenterological Association and professor at the University of Michigan. Allen is an advisory board member at Lynx.MD.
“Both practice consolidation and advances in health IT provide opportunities to analyze the value gastroenterologists provide to our patients,” Allen said. “Gastro Health is a large, multi-state GI practice where patients’ health journeys are documented in a single electronic medical record. They have partnered with Lynx.MD—whose technology enables secure data extractions and sorting from multiple clinical and administrative databases, and conversion into robust information—to gain insight into the longitudinal impact of care and enable improved point-of-care decision support.”
Creating one of the richest repositories of gastroenterology clinical data with Gastro Health opens up millions of data points for life-changing research, said Omer Dror, CEO and co-founder of Lynx.MD.
“Over three million people in the U.S. suffer from IBD, and the CDC estimates that up to 15% [of American adults] suffer from IBS,” Dror said. “Access to real-world data will advance the development of new therapeutics and treatments that can change the quality of patients’ lives.”
The collaboration will provide Gastro Health with deep, data-informed insights to achieve value-based care goals and will help realize the largest secure, privacy-compliant, real-world GI dataset for researchers around the world.
Lynx.MD is the leading cloud-based platform that unlocks real-world health data at scale. The platform enables the sharing and analysis of rich, unstructured data, securely connecting healthcare organizations with the life sciences and MedTech community.
 

### Will Smith: 'I vlogged my colonoscopy'
https://www.youtube.com/watch?v=eWwKQjUyoUc&feature=youtu.be

### STERIS | US Endoscopy announces full market release of the Acu-sInQ® Complete Endoscope Cleaning Aid System
STERIS | US Endoscopy, a leader in endoscopy device design and manufacturing, announces the release of the Acu-sInQ® Complete Endoscope Cleaning Aid System – a five-in-one unit, designed to provide a consistent, guided approach for increased quality control during the cleaning phase of the reprocessing cycle. The Acu-sInQ® Complete System is compatible with the STERIS | US Endoscopy portfolio of chemistries and has been validated for use with flexible endoscopes with channel diameters between 0.75mm – 6.0mm.
Cleaning an endoscope thoroughly and effectively can be difficult, but is essential to help prevent infections in GI endoscopy procedures. Proper manual cleaning of an endoscope involves a stringent, and sequential method. The new Acu-sInQ® Complete Endoscope Cleaning Aid System directs the user through the process of compliant cleaning and provides an on-screen interface to guide staff through each essential cleaning step. This cleaning process prepares the endoscope for high-level disinfection or sterilization. The Acu-sInQ® Complete Endoscope Cleaning Aid System is a solution that offers our Customers automated leak testing, dosing, temperature monitoring, flushing, and data management capabilities.
“STERIS | US Endoscopy is committed to offering a complete solution to support our Customers through each step of the endoscope reprocessing cycle,” says Tony Siracusa, Vice President and General Manager of STERIS | US Endoscopy. “The new Acu-sInQ® Complete Endoscope Cleaning Aid System offers our Customers a simplified approach allowing them to manage the cleaning process for their endoscopes in an intuitive and compliant manner.”
For more information: www.usendoscopy.com, or call 1-800-769-8226.

### VIA® procedure kits line extensions
STERIS | US Endoscopy, a leader in endoscopy device design and manufacturing, is proud to expand our VIA® procedure kits portfolio with two new offerings. The new procedure kit configurations are designed to simplify ordering, decrease room setup and turnover time and offer a unique mix of supplies including our newest infection prevention product – the BioGuard® air/water cleaning adapter – Olympus.
The BioGuard® air/water cleaning adapter – Olympus is designed to flush the air/water channel during the bedside pre-cleaning process. The new air/water adapter is disposable, offering an alternative option for manual reprocessing and the need to be tracked with a specific endoscope. These two additional kit options join our extensive line of VIA® procedure kits, custom kits, compliance kits, and sponges – additional information on the full portfolio can be found at www.usendoscopy.com/procedurekits.
“STERIS | US Endoscopy has seen an increase in Customer requests for additional kitting options that include more of our infection prevention products,” says Tony Siracusa, Vice President and General Manager of STERIS | US Endoscopy. “We are committed to expanding our portfolio and delivering solutions that help support our Customers’ practices as facilities continue to focus on workflow efficiencies and patient safety.”
For more information, call: 1-800-769-8226

### STERIS | US Endoscopy announces full market release of the Roth Net® retriever – 360
STERIS | US Endoscopy, a leader in endoscopy device design and manufacturing, announces the release of the Roth Net® retriever – 360. The newest addition to our extensive Roth Net® retriever portfolio is designed to offer optimal control during retrieval of the most challenging polyp, foreign body and food bolus endoscopy procedures.
Tissue and foreign body endoscopic retrieval can often be challenging and time consuming for clinicians. The new Roth Net® retriever – 360 helps to address these challenges by featuring a new spade shaped snare form and alternative net weave for durability and strength needed throughout these procedures. The innovative retrieval net also offers 360-degree, one-to-one rotation allowing for controlled net placement and alignment even when in tortuous anatomy or a retroflexed position.
“For over 25 years, STERIS | US Endoscopy has led the innovation and development of unique solutions for foreign body and polyp retrieval,” says Tony Siracusa, Vice President and General Manager of
STERIS | US Endoscopy. “As a trusted partner amongst our Customers, we are excited to introduce the innovative Roth Net® retriever – 360 offering best-in-class features. In addition to our broad portfolio of products, we are committed to providing education and in-servicing to ensure our Customers are well prepared for these situations."
For more information, visit www.usendoscopy.com.

### MSU Spartan Pride Scrub Hats and Bouffant Caps
Healthmark Industries is excited to announce the addition of Michigan State University Scrub Hats and Bouffant Caps to its Personal Protection Equipment (PPE) accessory line.
Officially licensed by MSU, these scrub hats and bouffant caps are of high quality and are perfect for any Spartan fan! Each cap and hat has the optional style of MSU basketball, Sparty, hockey or football. Disposable scrub hats are manufactured from spunlace non-woven rayon material. Disposable bouffant caps are manufactured with latex-free polypropylene fabric and have an elastic headband for a secure and comfortable fit. The reusable scrub hats are hand-tailored from pre-washed 100% cotton fabric, are machine washable and are one size-fits-most. Both the disposable scrub hats and disposable bouffant caps are one-size-fits-most.
All of our MSU scrub hats and bouffant caps cover the head, nape of neck and ears to confine hair, limiting it as a source of possible contamination, allowing healthcare professionals to complete their important duties all while displaying their Spartan Pride!
Visit www.hmark.com or call 800-521-6224 for more information.

### E. coli gain edge by changing their diets in inflammatory bowel disease
What if you had to plan your outings based on how your stomach felt that day or where the nearest restroom is located? For many people with inflammatory bowel disease (IBD), their guts have an inordinate effect on their daily quality of life.
One of the most common forms of IBD, called Crohn’s disease, is characterized by inflammation within the digestive tract and can lead to severe diarrhea, pain and weight loss. What causes IBD is still a mystery, but scientists now know that the gut microbiome, composed of the trillions of bacteria that make their home inside the intestines, are key players.
In a new paper in Nature Microbiology, Michigan Medicine researchers describe how bad bacteria gain a foothold over good bacteria in IBD and how something as simple as a diet change might reverse it. “The same bacteria are present in healthy and inflamed digestive tracts,” says Nobuhiko Kamada, PhD, of the division of gastroenterology in the department of internal medicine. “They just change their competition. We wondered what is the mechanism behind this?”
Although E. coli, the notorious bacteria behind many cases of food poisoning, is present in a normal healthy gut, the disease-causing form of the bacteria is able to outcompete its more benign cousins when the gut is inflamed. In earlier work within the Michigan Microbiome Project , Kamada’s team showed that the bad version of E. coli is usually held in check by good E. coli and other beneficial bacterial species through the metabolism of carbohydrates, the preferred source of nutrients for E. coli. Under inflammation however, the amount of good bacterial species is reduced, leaving less available sugar for E. coli to use and grow. Yet, the disease-causing E. coli are still able to take over.
The team hypothesized that the bad E. coli must change their dietary preference from sugar to something else, giving it an edge over other bacteria. In fact, their experiments with mouse models found that the bad E. coli developed a taste for amino acids, particularly serine, when their environment was inflamed. “We found that pathogenic E. coli had upregulated genes for serine metabolism,” said first author Sho Kitamoto, PhD, a research fellow in Kamada’s lab. Furthermore, the team was able to control the overgrowth by feeding mice with IBD a low serine diet.
Together, these findings hint at a possible mechanism for controlling bad bacteria through nutrition. “Of course, we could use antibiotics to kill the bad bacteria,” said Kamada. “But the gut microbiota plays a beneficial role to the hosts biology, and antibiotics kill the good guys along with the bad guys.”
They hope to eventually collaborate with clinicians to investigate the effects of personalized therapeutic diets for patients with IBD.
Said Kamada, “We have to carefully consider a patient’s disease status. One type of diet might be effective in patients under remission but not in patients with active disease.”
Source: UNIVERSITY OF MICHIGAN/MICHIGAN MEDICINE

### Business Partnership May Increase Delivery of Gut-Directed Hypnotherapy for IBS Patients
GI OnDEMAND, a virtual integrated-care platform, recently announced a partnership with Mindset Health, the creator of Nerva, a six-week, gut-directed hypnotherapy program. The hypnotherapy program is delivered through a mobile app to help patients with irritable bowel syndrome (IBS) better manage their symptoms.
GI OnDEMAND is a joint venture between the American College of Gastroenterology (ACG) and Gastro Girl, Inc., and now provides GI OnDEMAND and ACG members nationwide an evidence-based program to deliver gut-directed hypnotherapy to their IBS patients.
“Given the multifactorial nature of IBS, a multidisciplinary approach that includes brain-gut behavioral therapies is critical for many patients,” said Megan Riehl, PsyD, of the University of Michigan, and director of behavioral health services at GI OnDEMAND. “Direct access to a GI psychologist remains limited and has been a significant barrier to receiving this evidence-based care. Providers now have a trusted solution for access issues with an excellent product. Nerva is a self-directed digital therapeutic with proven benefits that patients will find easy to use and effective.”
Nerva’s program was designed by Dr. Simone Peters, a gastroenterology researcher and gut-directed hypnotherapist, whose study at Monash University uncovered that gut-directed hypnotherapy is as effective as the gold-standard low-FODMAP diet in helping patients with IBS manage their gastrointestinal symptoms.
“Nerva presents an exciting opportunity to provide app-delivered, gut-directed hypnotherapy to IBS patients from the comfort of their own homes,” said Dr. Peters, head of clinical content at Nerva. Peters, an adjunct research fellow at Monash University’s Department of Gastroenterology, is also the founder of Mind + Gut Clinic.
“Nerva’s durable effects on overall and individual gastrointestinal symptoms are similar to those observed with the low-FODMAP diet and those seen in face-to-face trials,” Peters said. “Despite high rates of efficacy, gut-directed hypnotherapy has long been inaccessible due to limited numbers of GI psychologists, long wait-lists and high costs associated with therapy, but Nerva provides an exciting solution to these overcome these barriers.”
About GI OnDEMAND: GI OnDEMAND is a joint venture between the ACG and Gastro Girl, Inc. A gastroenterology multidisciplinary virtual care platform, GI OnDEMAND brings the full ecosystem of GI experts, resources and support together for GI clinicians and patients. According to the company, GI OnDEMAND makes it easier for GI practices to adopt a virtual integrated-care model and amplify the expertise and value the practice brings to patients by providing access to vetted GI expert registered dietitians and GI psychologists, as well as genetic testing and expert genetic counseling. GI OnDEMAND also features telehealth capabilities and access to evidence-based educational programs.
About Mindset Health/Nerva: Since 2019, Mindset Health has helped more than 100,000 people learn to self-manage their health by making evidence-backed hypnotherapy accessible to everyone from their phone. Mindset Health works with world-leading researchers and healthcare associations to bring digital therapeutics for underserved health conditions to the world. Nerva was created to increase access to gut-directed hypnotherapy.
About Gastro Girl: Since 2016 Gastro Girl has served as the official patient-education partner of the ACG. Gastro Girl and ACG expanded this partnership in 2019 to make digestive-health expertise, resources and support available to everyone via GI OnDEMAND. In addition to connecting patients to GI experts—including gastroenterologists, registered dietitians, and psychologists—via GI OnDEMAND, Gastro Girl delivers actionable and evidence-based health information and resources to help everyone achieve better health.
 

### Quick Turnover 2-Part Clean-Dirty Label
Healthmark Industries is excited to announce the Quick Turnover 2-Part Clean-Dirty Label to its Labeling line. Designed as a communication tool for healthcare workers transporting items considered clean or a biohazard, the Quick Turnover 2-Part Clean-Dirty Label allows individuals to note items that are required for upcoming procedures and time needed. The tags ensure that healthcare staff can safely identify the status of equipment as each tag is brightly colored for high visibility.
The Quick Turnover 2-Part Clean-Dirty Label is 3.125” x 5.125” with two perforated tabs; a green tab with “TRANSPORTATION TAG” in black text, a red bottom with “QUICK TURNOVER” in black text along with a space to indicate items and time needed, as well as a green tab with “CLEAN” in black text and a fluorescent orange bottom featuring a biohazard symbol with “DIRTY” and “BIOHAZARD” in black text. The tag has a removable OSHA compliant adhesive backing that’s easy to apply.
Visit www.hmark.com or call 800-521-6224 for more information.

### BioGuard® air/water cleaning adapter – Olympus
STERIS | US Endoscopy, a leader in endoscopy device design and manufacturing, announces the release of the BioGuard® air/water cleaning adapter – Olympus. The new cleaning adapter is designed specifically for Olympus GI endoscopes*, offering a single-use option that clears the air/water channel during the bedside pre-cleaning process.
The endoscope bedside pre-cleaning process, for which the BioGuard® air/water cleaning adapter – Olympus has been specifically designed, is critical in helping to remove any debris from the air/water channels that are not manually brushed during the cleaning step of the reprocessing cycle. The new air/water cleaning adapter is disposable, providing an alternative option to manual reprocessing and the need to be tracked with a specific endoscope. The unique appearance and attached warning tag help prevent use during patient procedures.
“The BioGuard® air/water cleaning adapter – Olympus provides a differentiated solution for our Olympus Customers who are looking for a disposable option,” says Tony Siracusa, Vice President and General Manager of US Endoscopy. “This addition to our BioGuard® valve portfolio reiterates our commitment to delivering solutions that address unmet needs in the market, support industry guidelines and improve patient care.”
*Compatible with Olympus GI endoscopes, excluding EUS echoendoscopes that utilize a balloon channel.
For more information call: 1-800-769-8226 or click here.

### Electronic health records fail to detect up to 33% of medication errors
Despite improvements in their performance over the past decade, electronic health records (EHRs) commonly used in hospitals nationwide fail to detect up to one in three potentially harmful drug interactions and other medication errors, according to scientists at University of Utah Health, Harvard University, and Brigham and Women's Hospital in Boston. In tests using simulated medical records, the researchers found that EHR systems consistently failed to detect errors that could injure or kill patients.
"EHRs are supposed to ensure safe use of medications in hospitals," says David C. Classen, MD, the study's corresponding author and a professor of internal medicine at U of U Health. "But they're not doing that. In any other industry, this degree of software failure wouldn't be tolerated. You would never get on an airplane, for instance, if an airline could only promise it could get you to your destination safely two-thirds of the time."
The study appears in the journal JAMA Network Open.
First deployed in the 1960s, EHRs replaced written medical records and manual filing systems. They became almost universally adopted in the early 21st century after an Institute of Medicine report found that medical errors accounted for 1 million inpatient injuries and 98,000 deaths annually. According to the report, medication safety problems were the most frequent cause of preventable harm.
Medical professionals hoped that widespread use of EHRs would reduce this problem. The computerized systems are designed to issue warnings to doctors if their orders for medication could result in allergic reactions, adverse drug interactions, excessive doses, or other potentially harmful effects. However, recent studies suggest that medication safety and overall safety problems in hospitals continue to occur at a high rate despite the almost ubiquitous use of EHRs by hospitals.
One snag is that hospitals must customize and adapt their EHR software to meet their own needs, Classen says. This is a complex process that makes it difficult to keep up with all changes in drug safety. So, for example, a serious drug interaction that would trigger EHR warnings at one hospital might not at another one.
"Although EHRs are now widely used, their safety performance continues to vary from hospital to hospital," said David W. Bates, MD. a study co-author and chief of the Division of General Internal Medicine and Primary Care at Brigham and Women's Hospital in Boston. "Hospitals decide what drug-related decision supports to turn on within their systems. They have a great deal of latitude around this."
However, Classen said federal regulators only inspect EHR systems with factory specifications, meaning that whatever alterations hospitals make after installation aren't accounted for.
To determine the effectiveness of EHRs in real-world settings, Classen, Bates, and colleagues studied the results of tests conducted by an EHR safety evaluation tool called Leapfrog CPOE EHR test, which simulated actual drug orders that have and could potentially harm patients. Almost all of the scenarios were based on actual adverse drug events that harmed or killed patients in the real world.
In one scenario, for instance, a 52-year-old woman is admitted to the hospital with pneumonia. Prior to hospitalization, she was taking warfarin, a blood-thinning medication, once a day to combat deep vein thrombosis. After admission, she receives warfarin three times a day. This excessive dosage goes undetected by the hospital's EHR system for five days. As a result, the patient has a large hemorrhage and dies of causes directly related to the overdose of warfarin.
Scenarios like this one were fed directly into EHR systems at 2,314 hospitals nationwide to see if their systems would perform better. All of the tests were conducted over a 10-year span, 2009 to 2018.
The researchers found that, in 2009, these systems correctly issued warnings or alerts about potential medication problems only 54% of the time. By 2018, EHRs detected about 66% of these errors.
"These systems meet the most basic safety standards less than 70% of the time," the researchers concluded. "These systems have only modestly increased their safety during a 10-year period, leaving critical deficiencies in these systems to detect and prevent critical safety issues."
In addition, Classen noted that the hospitals in this study used the EHR evaluation tool on a voluntary basis to improve patient safety and care. Many hospitals do not participate in such evaluations, suggesting that the true safety performance of U.S. hospitals could be worse than the study found.
Source: University of Utah Health

### Decontamination Gowns
Healthmark Industries is delighted to introduce the Decontamination Gowns to its Personal Protection Equipment product line. Designed for use in device reprocessing areas, the Decontamination Gowns meet AAMI PB70 Class 4 requirements for liquid barrier performance while providing a high level of strikethrough resistance in the most vulnerable zone, protecting healthcare workers from soil and bioburden when cleaning items.
The single-use (one person - one day) Decontamination Gowns are comprised of two materials. The upper and lower zones are manufactured of a breathable material that is AAMI PB70 Class 4 that passes ASTM F1670 & F1671 test methods. The middle zone is manufactured of a completely liquid impervious zone, including preventing strikethrough of detergent cleaning solutions, even when physically leaning against sinks or other cleaning baths. The wrap-around Decontamination Gowns (360o coverage) come with elastic wrists, thumb loops, as well as neck and waist ties long enough to tie in the front or back. Use of the Decontam Gowns eliminates the need for wearing a plastic apron, or other secondary protection, even while providing superior protection. This improves worker comfort and dexterity. Sizes range from Small-Medium, Large-X-Large, XXL-XXXL, and XXXXL.
Visit www.hmark.com or call 800-521-6224 for more information.

### Single-Use Instrument Tube Brushes
Healthmark is pleased to announce the addition of the Instrument Tube Brushes to its ProSys™ instrument care product line.
Designed as single-use brushes, the Instrument Tube Brushes assist with the cleaning of internal lumens and channels of various sizes. Manufactured to facilitate maximum cleaning performance while ensuring compatibility with the channels of cannulated items, the nylon bristle brush tips connect to a stainless-steel wire and joins to a versatile acetal tubing, which provides adequate debris removal without causing damage.
These new brushes are offered in lengths of thirty and sixty centimeters and have the following different colored shafts that indicate the brush head diameters: White (2mm & 15mm), Black (4mm), Blue (6mm), Green (9mm), and Gray (12mm). The ITB Brushes are available for purchase in a package of thirty.
Visit www.hmark.com or call 800-521-6224 for more information.

### US Endoscopy announces full market release of the Torrent™ irrigation pump
US Endoscopy, a leader in endoscopy device design and manufacturing, announces the release of the Torrent™ irrigation pump. The new Torrent™ irrigation pump completes the existing line of Torrent® irrigation solutions (including the 24-hour Torrent® irrigation tubing and single-patient use scope connectors) and is designed for endoscopic irrigation in conjunction with an endoscope water jet and working channels.
 
Irrigation is recognized as an important part of a gastrointestinal procedure to clear any debris (i.e. blood, stool, etc.) from the mucosal wall. The durable, Torrent™ irrigation pump is designed to provide physicians with a hands-free option for irrigation during gastrointestinal endoscopic procedures allowing for a complete examination. The compact irrigation pump has also been optimized to provide consistent flow rates when used in conjunction with the 24-hour Torrent® irrigation tubing and single patient use Torrent® scope connectors.
 
“Our Customers are looking for a total solution to support their intraprocedural irrigation needs,” says Tony Siracusa, Vice President and General Manager of US Endoscopy. “The addition of the Torrent™ irrigation pump to our consumable solutions was the next natural step in allowing US Endoscopy to become a dependable, sole source provider for our Customers.”
 
About US Endoscopy
US Endoscopy, a subsidiary of STERIS Corporation, is a leader in endoscopy device design and manufacturing, serving the U.S. and international gastrointestinal endoscopy Customers.  By listening and delivering solutions in the field of endoscopy, our unique lines of devices provide better, more enhanced product options for GI clinicians.  A significant and growing portion of sales are from endoscopic devices created by the company's new product development team with the guidance and direction of physicians and nurses worldwide.  For more information, visit www.usendoscopy.com.
About STERIS Corporation
The mission of STERIS Corporation is to help our Customers create a healthier and safer world by providing innovative healthcare and life science product and service solutions around the globe. For more information, visit www.steris.com.

### Swanky Athletic Socks
Healthmark is pleased to announce the addition of Swanky Athletic Socks to its Personal Protection Equipment accessory product line. Energize your tired legs with our fashionable and comfortable Swanky Athletic Socks that deliver controlled pressure from ankle to calf for better blood flow throughout the lower leg.
Designed to enhance circulation the Swanky Athletic Socks provide support, help relieve foot and leg fatigue, as well as reduce swelling and recovery time for the active individual. Ideal for everyday wear, the socks are made with built-in arch support, a non-restrictive top, and help reduce muscle strain. The Swanky Athletic Socks have a 10-14 mmHg gradient compression and are made from 90% Nylon, 8% Elastic, 2% Spandex. The socks are offered in a Medium size: 6-10 (Women shoe size) and 5-9 (Men shoe size).
Visit www.hmark.com or call 800-521-6224 for more information.

### Fine Mesh Basket with Snap-Closure
Healthmark Industries is pleased to announce the addition of the Fine Mesh Basket with Snap-Closure to its ProTech® product line. Manufactured from stainless steel, the Fine Mesh Basket with Snap-Closure is 105 x 70 x 25 mm and ideal for safely washing small items that often get lost in instrument washers. The small perforations ensure effective water penetration during reprocessing. Simply place items in basket, close lid of basket and place into instrument washer for cleaning. The Fine Mesh Basket with Snap-Closure is available for individual purchase.
Visit www.hmark.com or call 800-521-6224 for more information.

### ProFormance™ QA Updated and Available Online
Healthmark is pleased to announce an updated version of ProFormace™ QA 2.1 software that is now available as a cloud-based application.
ProFormance™ QA 2.1 is a secure database that allows you to record key statistics for the performance of your decontamination procedures, including the test results from Healthmark’s ProFormance™ line of monitoring products. With this web-based application you can record data, use the information to generate impactful reports and track the performance of your cleaning equipment over a period of time.
To begin the setup process go to https://www.proformanceqa.com. Then, please call 800-521-6224 ext. 6657 or email proformanceqa@hmark.com to schedule a call with the ProFormance™ QA Help Desk.  
Visit www.hmark.com or call 800-521-6224 for more information.

### Histoguide™ wire-guided forceps
biliary duct endoscopy instrumentation ERCP Product Locator Surgical
US Endoscopy, a leader in endoscopy device design and manufacturing, announces the release of the Histoguide™ wire-guided forceps - designed to offer safe and effective placement of forceps into the biliary ductal system along a guidewire to facilitate stricture diagnosis during ERCP (endoscopic retrograde cholangiopancreatography) procedures.
ERCP procedures are most commonly performed on patients presenting with symptoms of biliary obstruction, making a proper tissue diagnosis vital in order to determine the best treatment options. Current biliary sampling techniques can be challenging, time consuming, and expensive.
The single-use Histoguide™ wire-guided forceps is a novel ERCP device that tracks along a guidewire to facilitate fast and effective biliary sampling. The standard size forceps with serrated jaws allows physicians to effectively grab and acquire tissue to aid in diagnosis and can be visualized under fluoroscopy. The unique, spring-loaded handle ensures the forceps remain in a closed position to retain the collected tissue samples for pathology.
“The new Histoguide™ wire-guided forceps is a simple and inexpensive solution that addresses the challenges associated with biliary stricture tissue sampling,” says Tony Siracusa, Vice President and General Manager of US Endoscopy. The new Histoguide™ wire-guided forceps joins the clinically proven Infinity® ERCP sampling device. Utilizing these devices for a two-tiered, multi-modality sampling approach may help improve diagnostic capabilities and lead to increased sensitivity during ERCP procedures.”*
About US Endoscopy
US Endoscopy, a subsidiary of STERIS Corporation, is a leader in endoscopy device design and manufacturing, serving the U.S. and international gastrointestinal endoscopy Customers.  By listening and delivering solutions in the field of endoscopy, our unique lines of devices provide better, more enhanced product options for GI clinicians.  A significant and growing portion of sales are from endoscopic devices created by the company's new product development team with the guidance and direction of physicians and nurses worldwide.  For more information, visit www.usendoscopy.com.
About STERIS Corporation
The mission of STERIS Corporation is to help our Customers create a healthier and safer world by providing innovative healthcare and life science product and service solutions around the globe. For more information, visit www.steris.com.

### Crohn’s & Colitis Foundation selected for FDA MyStudies app project
The Crohn’s & Colitis Foundation was selected as one of two patient organizations to participate in an U.S. Food & Drug Administration (FDA) Real-World Evidence Program demonstration project using the FDA MyStudies App through the FDA-Catalyst system. The FDA Real World Evidence Program will inform the assessment of the fitness for use of real-world data to support real-world evidence generation for regulatory decisions. Through the FDA MyStudies App, the Foundation will expand IBD Plexus®- a first-of-its-kind research information exchange platform and registry that centralizes data and biosamples from diverse research cohorts -to incorporate the use of a mobile application designed to fill in important real-world data gaps and capture patient experience data beyond the clinical care system.
Using the FDA MyStudies App technology, an open source mobile device and data storage system, the Foundation will launch IBD PROdigy, a digital IBD tracker tool that facilitates collection of longitudinal patient-reported data at critical points throughout a patient’s disease course. Through the IBD Plexus platform, the Foundation will then be able to link patient-reported outcomes data collected through IBD PROdigy to robust clinical data, biosamples, and their derived molecular (genetic and 'omics) data. IBD PROdigy will be initially rolled out to the SPARC IBD cohort – a Foundation-supported, multi-centered longitudinal study of adult IBD patients focused on identifying predictors to help find the right therapy for the individual patient. The goal would then be to release IBD PROdigy to additional IBD Plexus study cohorts.
“IBD PROdigy will become a key link between patients’ experiences and scientific advancements in IBD, enabling deeper patient participation in research. We cannot gather real- world data efficiently and effectively from patients without engaging with user-friendly tools such as IBD PROdigy,” said Angela Dobes, the Foundation’s senior director, IBD Plexus. “The more the app improves our interaction with patients, the more valuable and enriched data we will get. This app will engage patients and enable us to follow and learn from them throughout their disease journey.”
The FDA Center for Drug Evaluation and Research Office of Medical Policy is currently leading Real-World Evidence demonstration project efforts, which will evaluate the potential use of real-world evidence to help support the approval of new indications for approved drugs, consistent with the expectations outlined in the 21st Century Cures Act (21CC). The 21CC Act is designed to help accelerate medical product development and bring new innovations and advances to patients who need them faster and more efficiently. The FDA’s Real-World Evidence framework describes the sources of real-world evidence, gaps in data collection activities, standards, and methodologies for collection of the real-world evidence, and priority areas.
The MyStudies mobile device application and platform were developed to facilitate the input of real-world data directly by patients in a secure environment and to link patient-reported / generated data to electronic health data supporting traditional clinical trials, pragmatic trials, observational studies, and registries.
“FDA involvement with IBD Plexus provides our Real-World Evidence Program important experience with an exchange platform that uses multiple sources of health data, including real-world data,” said David Martin, MD, associate director for Real-World Evidence Analytics, Office of Medical Policy, FDA CDER. “In addition, collaborating with the Crohn’s & Colitis Foundation has allowed for improvements to the FDA MyStudies App that otherwise might not have occurred. The public will certainly benefit from these advancements as we evolve the field of real-world evidence through demonstration projects like this one.”
“IBD PROdigy will provide IBD Plexus cohorts the opportunity to fill in important information gaps critical to advance research,”Dobes added. “Periodic data collection that happens within the clinical delivery system only offers a snapshot into a patient’s disease. The app will allow us to fill in known missing care events, such as ER visits, and also incorporate patient’s symptoms and experiences. Linkage of this patient-reported data to clinical and molecular data then acts as a catalyst to augment research. These robust, multi-dimensional datasets will lead to stronger evidence to support and help expedite regulatory decisions.”
IBD PROdigy will launch in early 2020, making the Foundation the first patient organization to leverage the technology for research. Ultimately, the IBD PROdigy app and IBD Plexus will give:
 	Researchers the ability to leverage real-world data to enhance clinical research efficiencies, including, but not limited to: reducing time and cost of study startup, such as patient recruitment; help support evidence development associated with regulatory decisions, including post-marketing safety studies; and opportunities for leveraging real world data to better understand hard-to-study sub-populations.
 	Clinicians the ability to leverage data to create more holistic interventions based on findings from both clinical trials and real-world evidence in order to improve overall health of patients and inform decision-making to provide better care.
 	Technologists the ability to leverage open source code developed during the implementation phase of the demonstration project, such as triggering of notifications and questionnaires based on a study event reported the electronic data capture system for a trial or registry, available at the FDA My Studies Mobile application Git Hub page.

### New FIS-005 - The Next Generation of Flexible Inspection Scopes
Healthmark has announced it launch of the FIS-005SK, the next generation of flexible inspections scopes to its ProSys™ Optical Inspection product line. Delivering unparalleled quality of image in an incredibly convenient and robust design. The scope is designed with a blue handle that includes a distal tip composed of a light source and camera lens at the end of a 110cm flexible blue shaft, which features white graduation marks. Manufactured for instruments 2.0mm in diameter or larger, the FIS-005 is the perfect tool to get a visualization of any potentially soiled or damaged item. With the Starter Kit Software is included, which installs on Windows 7, 8 & 10 PC’s which powers the FIS-005 and allows for viewing, recording and documentation. The starter kit includes the scope, USB Drive and case.
Visit www.hmark.com or call 800-521-6224 for more information.

### Study uncovers gap in widely accepted practice for safe endoscope drying
A recent study published in the American Journal of Infection Control found that the practice of drying an endoscope for just 10 minutes prior to putting it into storage does not produce a dry, patient-ready endoscope. Drying is an essential part of endoscope reprocessing, and this study challenges the current industry standards around drying procedures. This information fundamentally shifts how healthcare facilities should approach their drying procedures. This is significant because 20 million gastrointestinal procedures are performed with an endoscope annually.
The study, “Endoscope reprocessing: Comparison of drying effectiveness and microbial levels with an automated drying and storage cabinet with forced filtered air and a standard storage cabinet,” evaluated both dryness and microbial levels of endoscopes that had completed high-level disinfection and had been placed in an automated drying cabinet or a standard storage cabinet.
The results of the study showed the automated drying cabinet (ENDODRY Cabinet, Cantel Medical), using instrument grade air, dried the inner lumens of the endoscopes in 60 minutes and the external endoscope surfaces in three hours. The study also showed that the automated cabinet was able to store the endoscopes for up to 31 days without an increase in microbial levels. The standard cabinet showed an inability to dry the scopes at 24 hours and allowed microbial growth throughout the study.
Until this study, the accepted industry standard, supported by a widely cited study from 1991, was a minimum dry time of 10 minutes. However, the same study showed the endoscopes weren’t entirely dry after 10 minutes.
Effective drying helps preserve the patient-ready condition of an endoscope after high-level disinfection because removing moisture as soon as possible helps prevent foreign body microbial growth. Any microbes that may remain on the endoscope can proliferate in a dark, wet environment. Drying is crucial when the endoscope is going to be stored because a dry environment does not support microbial growth and can help prevent infection.
Source: Cantel Medical

### The One-Hour Indicator
Healthmark Industries is pleased to announce the addition of the One-Hour Indicator to its Endoscopy product line. According to the IFU of popular models of flexible endoscopes, the cleaning of the device must commence within one hour of post-procedure bedside cleaning. Designed to be a visual reminder to healthcare workers, the single-use indicator is a small 19 x 32mm tamper-proof label applied to a self-looping label for easy tagging of the endoscope.
To activate the indicator, simply press the blister on the strip, and upon activation a safe dye migrates along a one-hour display run-out window, which shows elapsed time. No preconditioning is required, there are no moving parts, and no power source is required.
Visit www.hmark.com or call 800-521-6224 for more information.

### SonoCheck™ Hook
Healthmark Industries is pleased to announce the addition of the SonoCheck™ Hook to its ProFormance™ Cleaning Verification product line. Manufactured from stainless steel, the SonoCheck™ Hook is designed to keep the SonoCheck™ in position to prevent movement by vibrations, allowing the user to check the different zones of the sonic tank. Simply attach the SonoCheck™ to the hook, insert into the sonic tank, run the equipment as directed in the SonoCheck™ IFU.
Visit www.hmark.com or call 800-521-6224 for more information.

### Arm Sleeves for Prep & Pack
Healthmark Industries is pleased to announce the addition of new styles of Arm Sleeves to its Personal Protection Equipment accessory product line.
AORN guidelines state that arms must be covered when preparing and packaging items in the clean assembly area of sterile processing, which is why Healthmark developed the arm sleeves for healthcare professionals working within the sterilization department. Designed as an alternative to the traditional long-sleeved scrub top or jacket, machine washable arm sleeves are a one-size-fits-most made from 80% Acrylic and 20% Nylon, featuring an elastic gripper to prevent the sleeve from sliding down the user’s arm. The sleeves are available in two fits - mid-stretch and wide stretch weave.
Visit www.hmark.com or call 800-521-6224 for more information.

### Custom Printed Headwear
Healthmark is pleased to announce that the introduction of Custom Printed Headwear to its Personal Protection Equipment (PPE) accessories line.
Custom-Printed Disposable Headwear is available in two styles: bouffant caps and scrub caps. Disposable Bouffant Caps are manufactured from latex-free polypropylene fabric and have an elastic headband for a secure and comfortable fit. Disposable Scrub Caps are manufactured from spunlace nonwoven rayon material and include a tie-back closure. Both styles are one size fits all and can be custom printed with the design of your choice! Healthmark’s Custom-Printed headwear is intended to provide style and comfort to healthcare professionals while following industry guidelines. Visit www.hmark.com or call 800-521-6224 for more information.
 

### New EndoPro-Cam<sup>®</sup>
Healthmark is pleased to announce the addition of the EndoPro-Cam® to its ProSys™ Optical Inspection product line. 
Designed for evaluating the condition of rigid endoscopes, the EndoPro-Cam® is a portable endoscopic video system providing 1080p high-resolution HD imagining that assists healthcare workers with inspection of their facilities' rigid scope to check if their device is damaged. 
Manufactured for visual inspection of rigid scopes after cleaning and prior to further processing, the lightweight ergonomic EndoPro-Cam® allows for image capture, recording, and adapts to any C-Mount coupler. Featuring a 4.3 inch LCD monitor, the EndoPro-Cam® is equipped with a Micro SD card slot, Micro USB port, and Mini HDMI port. The EndoPro-Cam® includes a rechargeable Li-ion battery power bank, Micro SD card for storage, and a Mini HDMI cable for secondary monitor usage. Additionally, the EndoPro-Cam® comes with a camera stand that has a test pattern card affixed to it, which allows the user to view the card through their rigid scope to observe a standard test pattern to determine the resolution and color bars to check for dark spots. 
 Visit www.hmark.com or phone 800-521-6224 for more information. 

### The Latest in Dress Code and Personal Hygiene for Endoscopy Processing Staff
Personal dress code and hygiene play an important role in infection prevention of staff and patients. Sometimes, we do not always take the time to ensure compliance, which is unacceptable. To understand this better, let’s look at the recommendations and their importance.
Personal Hygiene
Good personal hygiene involves keeping all parts of one’s external body clean and healthy. Developing and maintaining good personal hygiene habits is important for an individual’s physical and mental health. It is critical that employees of the GI/endoscopy suite demonstrate good personal hygiene. Individuals with poor personal hygiene provide an ideal environment for the growth of microorganisms, leaving the body vulnerable to infection. Conversely, when an individual maintains good personal hygiene, the body sheds fewer bacteria into the environment, which is important in an area where medical devices are being processed. Reprocessing flexible endoscopes is arduous and requires stamina, so reprocessing technicians should strive to maintain good health by eating a well-balanced diet and getting plenty of sleep.
According to the Centers for Disease Control, good personal hygiene includes body hygiene, frequent hand hygiene and nail hygiene.
Attire 
All personnel entering the processing area should change into clean surgical scrub attire provided by and donned at the facility. Reusable scrub attire should be laundered by a healthcare-accredited laundry (ANSI/AAMI ST65:2008, ANSI/AAMI ST79:2017, ANSI/AAMI ST91:2021, AORN 2021b). This is important to keep the microbial level to a minimum.
Attire should be changed daily or more often as needed (i.e., when wet, grossly soiled, or visibly contaminated with blood or other body fluids). All head and facial hair (except for eyebrows and eyelashes) should be completely covered with a facility-approved head covering. Personnel should remove and discard head coverings whenever they leave the decontamination area. Upon reentry to the area, they should apply a new head covering. Fallout from head and facial hair can contaminate devices after they have been cleaned. Therefore, compliance is recommended.
Shoes worn in the processing area must be clean, have non-skid soles, and be sturdy enough to prevent injury if an item drops on the foot. Open-toed and clog-type shoes should not be permitted because they will not protect the feet from injuries that could occur when items are dropped. Liquid-resistant shoe covers should be worn if there is potential for shoes becoming contaminated and/or soaked with blood or other bodily fluids (29 CFR 1910.1030).
Jewelry (including earrings, necklaces, rings, bracelets, and wristwatches) that cannot be contained within the surgical scrub attire should not be worn in the decontamination, preparation, high-level disinfection, sterilization, or sterile storage areas. Jewelry should not be worn because it is not easily or routinely cleaned on a daily basis. In addition, it can harbor microorganisms, can become dislodged and fall into processed items, and can cause holes in gloves or other barrier protection.
Wristwatches and rings can catch on equipment or instruments, injuring personnel or damaging the item or packaging. Rings can also interfere with effective hand hygiene. One study found a tenfold higher median skin-organism count on the hands of healthcare providers wearing rings (AORN, 2021b). Another found that finger rings increased skin surface bacterial counts; although hand hygiene reduced bacterial counts, there were more bacteria under the rings than on the adjacent skin or on the opposite hand (AORN, 2021b).
Cloth head coverings or long-sleeved jackets should be laundered in the same manner as surgical-scrub attire (i.e., either by designated facility personnel or by a healthcare-accredited laundry service). Home laundering processes cannot be standardized and might not be sufficient to eliminate pathogenic (disease-producing) organisms from scrub attire. The OSHA Bloodborne Pathogens Standard states that if a uniform becomes soiled with blood or body fluids, it must be laundered at the facility; the employee is not permitted to take the uniform home for laundering (29 CFR 1910.1030).
Whether employees should wear cover apparel (e.g., cover gowns, lab coats) when they leave the sterile processing area to travel to other areas of the healthcare facility should be determined by each facility and should comply with state and local regulations. If cover apparel is worn, it should be clean (AORN, 2021b). Employees should change into street clothes when they leave the healthcare facility or when traveling between buildings located on separate campuses. (ANSI/AAMI ST91:2021, AORN, 2021b) .
Personal Protective Equipment (PPE)
Wearing PPE is essential to personnel safety. PPE includes fluid-resistant jumpsuits and gowns, hair coverings, impermeable shoe coverings, surgical masks and face shields, eye protection, and gloves. PPE must not permit blood or other fluids to pass through to the employee’s clothing, skin, mouth, eyes, or mucous membranes under normal working conditions. And of course, PPE must be worn when necessary.
OSHA Regulations: PPE
The OSHA Bloodborne Pathogens Standard (29 CFR 1910.1030) requires employers to identify tasks that might put employees at risk for exposure to blood and/or other body fluids and to take appropriate measures to protect them from exposure. The type of PPE worn by an employee may vary, consistent with the tasks to be performed.
According to OSHA, the selected PPE must “not permit blood or other potentially infectious materials to pass through or reach the employee’s work clothes, street clothes, undergarments, skin, eyes, mouth or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used” (29 CFR 1910.1030(d)(3)(i)).
PPE use is not optional. It is the responsibility of the employer to provide appropriate PPE, ensure that it is used, and document and investigate failure to comply. Designated facility personnel should provide education and training for all employees regarding the appropriate PPE that should be worn for the tasks they perform and the potential health and disciplinary consequences for failure to do so. This training should be documented and routinely verified as part of the departmental competencies. The training should include the correct steps in donning and doffing PPE. 
Recommended PPE
According to ANSI/AAMI ST91:2021, because of the potential for soaking clothing, splashing, and the aerosolization of fluids and contaminants, and the consequent need to protect employees from exposure to both microorganisms and chemicals, appropriate PPE in the endoscope cleaning area includes the following items:
 	General-purpose utility gloves. Processing personnel should wear a style of glove that prevents contaminated water from contacting skin or personal clothing. General-purpose or higher-level utility gloves that are fitted at the wrist should be used. Gloves that are too short, do not fit tightly at the wrist, or lack cuffs do not provide adequate protection. Likewise, exam gloves should not be used for decontamination. Many glove manufacturers offer decontamination gloves, some of which are 18 inches long.
 	A long-sleeved, impervious (fluid-proof) or fluid-resistant gown or jumpsuit. When there is a possibility that attire can become soaked with blood or other potentially infectious material, a Level 4 gown (as defined by ANSI/AAMI PB70:2012) should be worn.
 	A fluid-resistant face mask and eye protection. PPE worn to protect the eyes from splash and/or splatter may include goggles, full-length face shields, or other devices that prevent exposure from all angles. Face masks provide protection for the mouth and nose.
 	Fluid-protective shoe covers with slip-proof bottoms. Shoe covers are recommended when there is a potential for shoes to become contaminated with blood or other body fluids (OSHA 29 CFR 1910.1030). Shoe covers should be removed before leaving the endoscope reprocessing area.
Reusable gloves, glove liners, aprons, and eye-protection devices should be decontaminated according to the manufacturer’s written IFU after each use. If the integrity of an item has been compromised, it should be discarded.
Personnel should remove torn gloves and thoroughly wash their hands before donning new gloves. After completing processing activities, they should remove PPE and wash their hands. Before handling processed endoscopes, personnel should don clean PPE (ANSI/AAMI ST91).
Before leaving the decontamination area, personnel should remove all PPE and wash their hands, being careful not to contaminate skin or the clothing worn beneath PPE. Designated facility personnel should educate and train employees about how to correctly don and doff PPE and ensure that designated areas and containers for clean and used PPE are provided.
The CDC offers an instructional poster for donning and doffing PPE. Developed during the Ebola outbreak a number of years ago, it continues to be used today. The only PPE not covered in the poster are shoe covers. The poster is available at:
https://www.cdc.gov/hai/pdfs/ppe/ppeposter148.pdf
Summary
The facility/department should have a policy on required dress code and ensure staff compliance. In addition, the policy should be referenced to AAMI and OSHA standards and AORN or SGNA Guidelines. There should also be a policy on the required PPE and since this is a regulation, monitoring staff compliance is critical.
According to the OSHA webpage on penalties, “Any serious violation (which non-compliance with PPE is considered) the potential fine is $15,625 per violation. Employers can be cited for violation of the General Duty Clause if a recognized serious hazard exists in their workplace and the employer does not take reasonable steps to prevent or abate the hazard. The General Duty Clause is used only where there is no standard that applies to the particular hazard. The following elements are necessary to prove a violation of the General Duty Clause: The employer failed to keep the workplace free of a hazard to which employees of that employer were exposed;
 	The hazard was recognized;
 	The hazard was causing or was likely to cause death or serious physical harm; and
 	There was a feasible and useful method to correct the hazard.
Therefore, PPE must be provided, in-serviced in its use and monitored for compliance for employee and patient safety.
Nancy Chobin, RN, AAS, ACSP, CSPM, CFER, is the president and CEO of Sterile Processing University, LLC, of Lebanon, New Jersey. Her company was founded in 1996 and provides SPD and GI consultations, competency assessments, design of sterile processing areas (in hospitals, surgery centers and endoscopy processing areas), on-site training, and online training courses for ambulatory surgery, SPD and endoscopy processing personnel.
Chobin consults for dental and medical offices where sterilization is performed. She has authored three textbooks and two workbooks, has provided chapters, and served as an editor for other textbooks on sterile processing. Chobin has lectured extensively in the United States; Latin, Central and South America; Mexico; and in Asia and Europe. Chobin has published numerous articles in a variety of professional magazines.
References
 	Association for the Advancement of Medical Instrumentation. Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities. ANSI/AAMI ST79:2017. Arlington (VA): AAMI, 2017.
 	Association for the Advancement of Medical Instrumentation. Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities. ANSI/AAMI ST79:2017, Amendment 1:2020. Arlington (VA): AAMI, 2020.
 	Association for the Advancement of Medical Instrumentation. Flexible and Semi-Rigid Endoscope Processing in Health Care Facilities. ANSI/AAMI ST91:2021. Arlington (VA): AAMI, 2022.
 	Basics of Flexible Endoscope Reprocessing 3rd Edition, 2022, Sterile Processing University, LLC, Lebanon, NJ.
 	Centers for Disease Control and Prevention. (December 1, 2022). Personal Hygiene. Retrieved from https://www.cdc.gov/hygiene/personal-hygiene/index.html
 	Occupational Safety and Health Administration. (December 20, 2022). OSHA Penalties. Retrieved from https://www.osha.gov/penalties
 	Occupational Safety and Health Administration. (December 18, 2003). Standard Interpretations. Retrieved from https://www.osha.gov/laws-regs/standardinterpretations/2003-12-18-1

### Companies Enter Partnership for Blood Test to Detect Colorectal Cancer and Pre-Cancer
SUNNYVALE, Calif., and ROSWELL, Ga.—CellMax Life, a molecular diagnostic firm with proprietary technology for the detection of pre-cancer and cancer blood tests, and Sebela Pharmaceuticals, a gastroenterology market leader, recently completed a strategic development and commercial partnership agreement, as well as CellMax's Series C financing.
The funding will go towards the acceleration of the clinical development of CellMax's multimodal liquid biopsy test, FirstSight, to detect colorectal cancer and pre-cancerous polyps, or advanced adenomas. CellMax just launched a multicenter U.S. trial to further refine its exclusive algorithm and cell capture methods.
CellMax and Sebela will jointly work to finalize the development of FirstSight and, after U.S. approval,. Food and Drug Administration, Sebela will make the test commercially available in the United States."For the past few years, we have been watching closely as the industry has been developing liquid biopsies for colorectal cancer," said Alan Cooke, chief executive officer, Sebela Pharmaceuticals.
"Sebela and our subsidiary, Braintree, have served gastroenterologists for more than 35 years, and we believe FirstSight will be a key player in the future of colorectal cancer screening.". FirstSight has the potential to not only help the U.S. reach beyond its target 80 percent screening rate goal, as defined by the National Colorectal Cancer Roundtable, but to identify pre-cancerous adenomas early on, referring them to colonoscopy for preventive removal.
"This deal fits nicely with Sebela's portfolio of gastroenterology and colonoscopy prep products that are used to make colonoscopies, the "gold standard" in prevention and detection of colorectal cancer, easier.". Colonoscopies are the sole method of removing pre-cancerous lesions found to prevent colorectal cancer.
At the 2021 American Society of Clinical Oncology (ASCO) Gastrointestinal Cancer Symposium, Stanford University Medical Center professor of medicine and VA Palo Alto Health Care System chief of gastroenterology Dr. Shai Friedland presented findings from a prospective study conducted on 458 participants using FirstSight, a multimodal assay consisting of circulating dysplastic epithelial cells and circulating tumor DNA mutation markers, with a proprietary algorithm.
"A test that finds only colorectal cancer, but not adenomas, will miss the chance to prevent cancer and expose patients to invasive cancer therapy," said Dr. Friedland. "Currently, there isn't one non-invasive screening exam that can reliably identify pre-cancerous polyps even as good as a colonoscopy. Our study results with the FirstSight blood test continue to demonstrate consistent capacity to detect advanced adenomas with high sensitivity, allowing removal before they become carcinomas."

### TRICOR Systems Inc. Announces Exclusive U.S.A. Distribution Agreement with SteriView Technologies, Inc.
Launching the SteriView Instrument Inspection System 
SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes states: “Visual inspection is an essential step to make sure the endoscope is visibly clean (AAMI, 2015; Rutala et al., 2008). According to Peterson (2017), all endoscopes and reusable accessories should be visually inspected during all stages of handling and reprocessing – before, during, and after use, in addition to during and after cleaning and before HLD (High-Level Disinfection). Visual inspection is not a guarantee that decontamination from manual cleaning is complete, but it can be considered a safety stop or “time out” to ensure the endoscope is visually clean before proceeding to the next step of HLD.” 
The Dri-Scope Aid® family of products have been on the forefront of finding a solution for every facility to dry their scopes properly after high-level disinfection. “While discussing the importance of drying the internal channels with Infection Prevention personnel, we have seen how scopes have been perceived dry after AER reprocessing or vertical air drying in a cabinet. We then used a borescope to look at the internal channels and found that the scopes still had remaining moisture in them if an automated forced air system (e.g. Dri-Scope Aid®) had not been used. We were also able to observe other irregularities with the internal channels,” said George Cronin, National Sales Manager. “Multiple society and manufacturer recommendations have outlined the importance of visual inspection to identify damage and verify reprocessing efficacy. This sent us on a mission to find the premier inspection system on the market which had the best visualization, documentation, and ease of use for the customer. SteriView fits all those needs.” 
TRICOR Systems Inc. is excited to announce the launch of the SteriView MIC (Modular Inspection Camera). TRICOR has been chosen as the exclusive United States distributor of the SteriView MIC. SteriView is the next generation of advanced small diameter, near field inspection scopes designed to provide ready access and imaging of the interior chambers, lumens, and working channels of surgical medical devices. The MIC’s removable insertion tube/camera can be High-Level Disinfected, providing the Infection Prevention team the ability 
For more information contact:
George Cronin, 1-508-423-3223
george@driscope.com

### FDA is Investigating Reports of Infections Associated with Reprocessed Urological Endoscopes
This week the U.S. Food and Drug Administration revealed it is probing several medical device reports (MDRs) of patient infections and other potential contamination problems related to reprocessing urological endoscopes, such as cystoscopes, ureteroscopes and cystourethroscopes—scopes for seeing and entering the urinary tract. Reprocessing these kinds of medical devices entails both cleaning and high-level disinfection or sterilization so the devices can be reused.
"FDA is looking at possible causes and contributing factors related to reported infections and issues with contamination related to reprocessed urological endoscopes," stated Jeff Shuren, M.D., J.D., director of FDA's Center for Devices and Radiological Health. "We are seriously concerned about the three reported deaths—outside of the United States—linked to these infections, and we're moving quickly to inform health care providers and the public about what we know and what remains an emerging issue.".
“While some reports indicate the potential causes could be inadequate reprocessing or device maintenance issues, we’re also evaluating other possibilities, including device design or the reprocessing instructions in the labeling,” Shuren continued. "While we feel that the risk of infection is low based on data available, we're reminding health care professionals how critical it is to adhere to labeling and reprocessing directions to thoroughly clean and reprocess the devices, including accessory components.". We seriously consider all adverse event reports and urge reporting to the FDA early in order to assist us in identifying and understanding the risks of reprocessed medical devices better."
Cystoscopes, cystourethroscopes and ureteroscopes are endoscopes used in urology that enable health care professionals to visualize and enter the urinary tract (e.g., urethra, bladder, ureters and kidneys) in diagnostic and treatment procedures.
From Jan. 1, 2017 to Feb. 20, 2021, more than 450 MDRs reported post-procedure patient infection or other potential contamination problems relating to reprocessing these devices have been received by the FDA. In those where the name of the device firm was given, either Karl Storz or Olympus Corporation were listed. MDRs may be submitted by mandated reporters, for example, importers and manufacturers and device user facilities, or by voluntary reporters.
Olympus filed three reports of patient death due to bacterial infection that had taken place outside the U.S. Two of those reports involved a forceps/irrigation plug, an accessory device used to manage water flow and allow access to the working channel of the endoscope. Laboratory tests revealed the same infectious bacteria in both the forceps/irrigation plug and the infected patient. The third report of patient death was a cystoscope that failed a leak test, suggesting potential damage to the device, which may have been a contributing factor to the infection. Whether and to what extent the reported infections or patient co-morbidities played a role in the patient deaths is unknown.
Note that MDRs alone are not the absolute proof of a defective or defective medical device and cannot be utilized to calculate or compare rates of event occurrence. The FDA continues to evaluate these reports, but the agency has not yet concluded that any particular manufacturer or brand of these devices is linked with increased risks compared to others.
The Letter to Health Care Providers released today offers guidance on how to reprocess and use these devices, such as adhering to the reprocessing instructions, not using a device that has failed a leak test, creating schedules for regular device inspection and maintenance, and informing patients of the possible benefits and risks of procedures involving reprocessed urological endoscopes.
Providing safety for reprocessed medical devices, which are utilized in more than one patient, is a collaborative effort between the FDA and other federal agencies, public health infrastructure, state and local health departments, medical device manufacturers, health care facilities, professional organizations and others. The FDA is actively involved to understand better the etiology and risk factors for transmission of infectious agents and to develop solutions to reduce patient exposure.
The measures the FDA is taking on urological endoscopes today draw from the agency's experience with duodenoscopes. From 2015 on, the FDA has communicated and acted regarding duodenoscope infection related to reprocessing, including issuing postmarket safety studies and revising sampling and culturing requirements. The agency also refined its guidance in 2015 to cover more device types that require reprocessing validation data. The FDA has sent Warning Letters to manufacturers and safety communications to the public and health care providers and conducted a public Advisory Committee meeting soliciting information on how best to reprocess medical devices. In addition, the FDA has prompted manufacturers to switch to devices that have features eliminating the need for reprocessing and assisted manufacturers in revising and validating their reprocessing instructions.
The issues FDA has found with urological endoscopes and duodenoscopes might extend to similar devices. Accordingly, the agency is also examining data on other endoscope types.
The FDA will continue to provide updates to health care providers and the public if new or further information comes in about adverse events and other topics concerning reprocessing urological endoscopes.
The FDA, a branch of the U.S. Department of Health and Human Services, ensures the safety, effectiveness, and security of human and animal drugs, vaccines and other biologic products intended for human consumption, and medical devices. In addition, the agency ensures the safety and security of our food supply, cosmetics, dietary supplements, products emitting electronic radiation, and for tobacco product regulation.

### New COVID-19 Signs
Healthmark has launched new customized signs to help healthcare facilities communicate important messages during this challenging time. 
In order to encourage and remind individuals of necessary steps to practice during this pandemic, Healthmark released COVID-19 Floor Signs. These signs have been designed to catch the attention of healthcare workers and visitors. There are a variety of designs for specific purposes, from labeling an area that is in quarantine, to a reminder to practice safe social distancing, to instructing personnel to don the proper PPE. Our COVID-19 Floor Signs have high visibility, can handle heavy foot traffic but are semi-adhesive for convenient removal. 
Additionally, released in concert are the COVID-19 Wall Signs. The different wall sign options serve as reminders to personnel to wash hands, practice safe social distancing, don the proper PPE or to alert personnel of a quarantine area. Healthmark can also design and produce custom signs to meet the individual needs of facilities. 
Visit www.hmark.com for more information. 

### Sebela Pharmaceuticals Receives FDA Approval for SUTAB® Tablets for Colonoscopy Preparation
BRAINTREE, Mass. — Sebela Pharmaceuticals® this week announced that the U.S. Food and Drug Administration (FDA) approved SUTAB® (sodium sulfate, magnesium sulfate, and potassium chloride) tablets. SUTAB, a sulfate-based tablet preparation for colonoscopy, was developed and will be marketed by Braintree Laboratories, the makers of SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution—the market leader in branded colonoscopy preparations.1 SUTAB gives patients and physicians an alternative to liquid-based colonoscopy preparations. Braintree, a leader in gastroenterology, is part of Sebela Pharmaceuticals.
Colonoscopy is the most common detection method for colorectal cancer, a leading cause of cancer-related deaths that can be managed more effectively through screening.2  It is considered the gold standard of colorectal cancer screening methods for its ability to view the entire colon and both detect and remove polyps during the same procedure.3,4 Nineteen million colonoscopies are performed in the U.S. every year.5 For those patients, particularly those who have had difficulty completing colonoscopy preparation in the past, SUTAB presents a welcome alternative to liquid bowel preparation.
“Successful bowel prep is critical for gastroenterologists to clearly see any polyps or abnormalities, yet the immense volume of liquid prep solutions can prevent patients from adequately completing their regimens. Tablets provide a welcome alternative for successful prep completion and visualization of the colon,” said Douglas K. Rex, M.D., director of endoscopy at Indiana University Hospital and Professor, Department of Medicine, Division of Gastroenterology and Hepatology, University of Indiana School of Medicine.
Alan Cooke, president and CEO of Sebela Pharmaceuticals, said, “Gastroenterologists and their patients have repeatedly asked for a safe and efficacious tablet bowel prep. Now patients can benefit from SUTAB, thanks to Braintree’s innovative and dedicated team, who have worked tirelessly to develop this important product. SUTAB’s FDA approval underscores Braintree’s more than 35-year commitment to gastroenterology.”
In two pivotal trials, 92 percent of patients achieved successful bowel cleansing with SUTAB6 and 92 percent to 95 percent of patients achieved successful cleansing in all segments of the colon, including the proximal colon.7 In one pivotal trial, 91 percent of patients rated SUTAB as very easy to tolerable to consume.7 Seventy-eight percent said they would request SUTAB again for a future colonoscopy.7  Fifty-two percent of all SUTAB and MoviPrep®8 patients reported at least one selected gastrointestinal adverse reaction.6 More SUTAB patients reported experiencing nausea and vomiting than the comparator, with ≤1% of these reports considered severe.6 
“The approval of SUTAB provides a welcome relief for patients who struggle with the unpleasant taste issues commonly associated with other products for colonoscopy preparation,” said Jack A. Di Palma, M.D., Professor of Medicine and Fellowship Program Director of the Division of Gastroenterology at the University of South Alabama College of Medicine and Past-President of the American College of Gastroenterology. “And because SUTAB contains the active sulfate ingredients similar to SUPREP, gastroenterologists will already be familiar with its effects.”
SUTAB will be available by prescription to patients in the U.S. on January 1, 2021.

### SeekNFind™ Tray Tag Tool
Healthmark Industries has introduced the SeekNFind™ to its Labeling product line. 
The SeekNFind™ provides a means to locate missing or mislaid trays and other assets. Made from PTFE Teflon, the 240 x 86mm RFID tag is assembled with stainless steel eyelets for attachment to instrument baskets and other assets. The RFID reader is paired with a Bluetooth® enabled Android phone. With the SeekNFind™ app, available for download from the Google Play store, tagged trays and other tagged assets can be more easily found, when missing. 
Visit www.hmark.com for more information. 

### SGNA to host virtual experience in 2021
Virtual Experience to replace Annual Conference in 2021
With the continued public health threat presented by the COVID-19 pandemic, SGNA’s Board of Directors has determined the safest way to bring our community together this spring is through a virtual event. SGNA will host the 48th Annual Course: A Virtual Experience May 22-25, 2021, with pre-meeting events May 21-22, through the same platform we used in fall 2020.
Rest assured, we all are eager to come together in person and are committed to doing so as soon as it is safe for us, our families and our communities. Please be on the lookout for additional event details for our upcoming virtual Annual Course, including online registration, in the coming weeks. In the meantime, please visit these frequently asked questions for more information.
The deadline to submit poster abstracts is January 31. Learn more.
Learn more about Annual Course scholarships and awards opportunities.

### HydroCheck™  Moisture Detection
Healthmark Industries is pleased to announce the introduction of the HydroCheck™ to its ProFormance™ Cleaning Verification line. 
Designed for detecting residual moisture in channels, the single-use HydroCheck™ is a user-friendly test kit that can detect as little as 0.05 μL of residual moisture, providing immediate results. Swabs are available in the following sizes: 1.7mm, 2.8mm, 3.8mm, and 5.0mm. If a detectable amount of residual moisture is present on the swab, there will be a visual color change to purple on the swab. Call 1-800-521-6224 or www.hmark.com for more information. 

### HMP Global Launches Gastroenterology Learning Network
HMP Global, a healthcare event and education company, this month announced the launch of the Gastroenterology Learning Network. The network aims to connect healthcare specialists around the world with clinically relevant news and information, expert perspectives, and continuing education.
The Gastroenterology Learning Network is a digital destination that offers practical content and education guided by input from gastroenterology professionals.
Visitors to the site can create a customized experience by selecting topics most pertinent to them. Visitors can also receive email updates with breaking news and curated content, and connect with other gastroenterology colleagues around the world through the platform's networking options.
"Now gastroenterologists and other providers will have access to this new network to stay informed on important clinical knowledge on emerging therapies and treatments on a broad spectrum of gastroenterological diseases, while enjoying a highly specialized content experience," said David DePinho, executive vice president in the Life Sciences Group at HMP Global. "As clinicians continue to navigate the complexities of patient care, particularly in the midst of COVID-19, gastroenterology professionals will benefit from this comprehensive platform filled with information and insight to improve decision making and provide the highest quality, patient-centered care."
For more information about the Gastroenterology Learning Network, visit gastroenterologylearningnetwork.com.

### Antibiotic-resistant bacteria more prevalent in device-related Infections
DetailsMonday, 25 November 2019
Healthcare-associated infections (HAIs) related to the use of medical devices are more likely to be antibiotic resistant than HAIs that result from surgical procedures, according to a report from the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN) published today in Infection Control & Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America.
“Combating antimicrobial resistance is a top clinical and public health priority in the United States,” said Lindsey Weiner-Lastinger, MPH, an epidemiologist at the CDC. “These data show that the threat of exposure to bacteria that are resistant to antibiotics extends across the nation. The data also serve as an urgent call for healthcare facilities and public health agencies to intensify their efforts to prevent the emergence and spread of antimicrobial resistance.”
The report, which summarizes data from 5,626 facilities from 2015 to 2017, shows that resistance was consistently higher for device-associated HAIs than for the same bacteria identified after surgical procedures. Devices studied were not permanent implants but rather devices used for limited time in a hospital setting such as central lines, ventilators, and urinary catheters.  For instance, 48 percent of tested Staphylococcus aureus isolated from device-associated infections were methicillin resistant (MRSA), compared to 41 percent among those isolated from surgical site infections; and 82 percent of tested device-associated Enterococcus faecium bacteria were resistant to vancomycin (VRE) compared to 55 percent among surgical site infections.
Researchers note that germs in adult and pediatric facilities varied by infection type and care location. The most common HAI bacteria among adult patients were Escherichia coli (18%), Staphylococcus aureus (12%) and Klebsiella (9%). A companion report on pediatric healthcare-associated infections, with data from 2,454 facilities, found the most prevalent pathogens among pediatric patients were Staphylococcus aureus (15%), Escherichia coli (12%), and coagulase-negative staphylococci (12%).
The data also show that bacteria associated with long-term acute care hospitals are more likely to be antibiotic resistant than those acquired in short-stay acute care hospitals; and HAIs in adult healthcare settings are more likely to be resistant than those in pediatrics.
NHSN collects and tracks data to identify problem areas in facilities, states, regions, and the nation, and to help measure the progress of prevention efforts.
Lastinger said the increasing availability of clinical and laboratory data in electronic form provides new opportunities to quickly identify resistance to antibiotic therapies and to inform antibiotic stewardship programs. Appropriate resources should be allocated to ensure proper infection prevention methods of devices and the environment across the healthcare continuum.
Source: Society for Healthcare Epidemiology of America

### Tamper Evident Probe Cover
Healthmark is pleased to announce the addition of the Tamper Evident Probe Cover to their Bags & Dust Covers product line. 
This cover is designed to keep probes covered to reduce the risk of contamination from the environment during transportation and storage. The 3 Mil single-use 14 x 4.5-inch Tamper Evident Probe Cover is manufactured from low density polyethylene, latex-free and non-sterile. The Probe Cover is sealed on three sides, and has vertical and horizontal perforations, as well as a tamper evident seal to help protect the probe from the environment by keeping the cord outside of the bag. 
Visit www.hmark.com or call 800-521-6224 for more information. 

### New LED Interchangeable Magnifier
Healthmark Industries has announced the addition of the LED Interchangeable Magnifier to its ProSysTM Instrument Care product line.
Designed for items to be optically inspected, the LED Interchangeable Magnifier is manufactured with an interchangeable 5-diopter glass lens that has a 2.25x magnification, 360 rotatable lamp head and a fully enclosed spring balanced arm to prevent pinching hazards. Equipped with 64 ultra-bright white SMD LEDs with brightness adjustable controls, the LED Interchangeable Magnifier has a reach of 36 Inches, max illumination of 950lm, wattage of 6W and includes a table clamp with a 2-inch opening. The LED Interchangeable Magnifier power supply has an input of 100-240V-50/60Hz -0.45A and output of 26V/500mA.
Interchangeable lenses are offered in the following magnifications and diopters: 2.25x (5 diopter), 3x (8 diopter), 4x (12 diopter), and 4.75x (15 diopter). The LED Interchangeable Magnifier is available for individual purchase. The Lenses can be purchased separately or together
Visit www.hmark.com or call 800-521-6224 for more information.

### New Heart of the Hospital Socks Offered by Healthmark
Healthmark Industries is pleased to announce the new Heart of the Hospital socks to its Personal Protection Equipment (PPE) line. 
Manufactured in America from 80% Acrylic, 20% Nylon and 10% elastic, the Heart of the Hospital socks are designed to honor CS professionals during Central Service Week and all year long. It is the tireless efforts of these unsung heroes that play an often underappreciated, critical role in the delivery of the best patient care. 
Made to provide (non-compression) support for the arch and bottom of the foot, the crew length Heart of the Hospital socks are a great addition to any medical professional’s wardrobe. The unisex Heart of the Hospital socks are available in Medium: 4-9 (Men shoe size) and 3-8 (Women shoe size); Large: 10-13 (Men shoe size) and 9-12 (Women shoe size). 
Visit www.hmark.com or call 800-521-6224 for more information. 

### Healthmark Offers New Scope Sleeve to Endoscopy Product Line
Healthmark Industries is delighted to introduce the Scope Sleeves to its Endoscopy product line. Manufactured of material comprised of 80% cellulose and 20% polypropylene, the single-use Scope Sleeves are designed to cover and protect insertion tubes after reprocessing, during transportation and storage. Open on both ends, the non-linting Scope Sleeves are made of an absorbent material that also provides a barrier to environmental contaminants. The Scope Sleeves are offered in three sizes: 85L x 5W cm, 115L x 5W cm and 190L x 5W cm. The Scope Sleeves are available for purchase in packs of one hundred. 
Visit www.hmark.com or call 800-521-6224 for more information. 

### Healthmark Offers New EndoDolly™
 Healthmark Industries is pleased to announce the new EndoDolly™ to their Endoscope Product Line. 
Manufactured from stainless steel, the EndoDolly™ is designed for hanging scopes and stands on a five-wheel locking base for ease of transportation. The EndoDolly™ is equipped with 3 self-adjusting extension poles that can be individually raised by simply touching a pressure button, which allows the user to extend the 2 outside poles to 8 feet and the middle pole to 10 feet. Located at the top of each pole is a lock-tight hook holder that can accommodate two scopes per pole and supports flexible scopes up to 15 lbs. per pole. Each self-adjusting pole comes with polycarbonate cups that allow for the scope tip to be placed in during transportation, storage, or quality assurance testing. 
Visit www.hmark.com or call 800-521-6224 for more information. 

### KEY SURGICAL INTRODUCES ENZYMATIC SOLUTIONS
Key Surgical LLC, a leading global provider of sterile processing, operating room, and endoscopy supplies, announces the addition of an enzymatic detergent and a pre-cleaning solution from Dr. Weigert, the leading authority in Europe for medical decontamination chemistries. With the new additions, Key Surgical continues to offer a comprehensive portfolio to hospitals and surgery centers for manual cleaning, disinfection, and sterilization of surgical instruments.
Key Surgical is the only distributor to introduce Dr. Weigert products to hospitals in the United States: neodisher®  MultiZym, a detergent for manual cleaning, and neodisher® PreStop, a spray foam used for pre-cleaning in the operating room. MultiZym and PreStop been used in CSSDs throughout Europe with proven success delivering effective, efficient cleaning results.
Dr. Weigert MultiZym is a multi-enzymatic detergent that delivers maximum cleaning results through a combination of three classes of enzyme: protease, lipase, amylase. MultiZym is specifically formulated for use in manual cleaning in sinks, immersion baths, and ultrasonics and features simple dosing. This pH neutral, low-foaming detergent is formulated to be safer for personnel and the environment while still delivering maximum results as it’s free of boric acid, borates, perfume/scent, and dye making it a user-friendly solution in the CSSD. Material compatibility includes surgical stainless steel, optics, standard synthetic materials, anodized aluminum, silicone, and materials used in anesthetic equipment. MultiZym is available as a 1.32 gal (5 L) bottle.
Dr. Weigert PreStop is a pre-cleaning product designed to apply to instruments after use in the operating room and before further reprocessing can occur. PreStop is an easy-to-use spray foam and helps prevent the growth of micro-organisms, corrosion, and potentially irreparable damage on instrumentation. Prevents the drying of surgical residues by keeping the instruments wet. Instruments treated with PreStop can be stored for up to 72 hours before reprocessing. Each bottle of PreStop is 25.4 fl oz (.75 L) and is packaged 12/case.
“Introducing an enzymatic detergent and a pre-cleaning product to our line is something we’re very excited about,” Alana Suomela, Director, Corporate Marketing at Key Surgical beams. “Customers have asked us for solutions like this (pun intended) and we’re thrilled to continue to support them with these new products; allowing them to focus on excellence in instrument reprocessing as it directly affects patient safety.”
For more information about these products from Key Surgical, visit www.keysurgical.com.

### Johns Hopkins Hosts Conference to Cover Advances in Endoscopy, Gastroenterology and Hepatology
Johns Hopkins Medicine will be hosting a conference to cover advances in endoscopy, gastroenterology and hepatology Saturday, March 13.
This one-day activity will provide an update on a wide range of topics of interest to the those in the endoscopy profession. Rapid advances are being made in the understanding of the pathophysiology, natural history and treatment of diseases of the digestive tract and liver. This course will offer practitioners a comprehensive overview of recent, cutting-edge advancements in gastroenterology and hepatology.
Particular areas of focus will be advanced endoscopic techniques, GI neoplasms, pancreatico-biliary pathology, liver diseases, hepatobiliary malignancies and liver transplantation.
This activity is intended for gastroenterologists, general surgeons, family physicians, internists, endoscopy nurses, endoscopy technicians and physicians interested in GI and liver disease.
Objectives
 	Describe the role of endoscopy in the management of duodenal polyps.
 	Summarize the role of Artificial Intelligence in endoscopy.
 	Outline current progress in endoscopic management of Barrett esophagus with dysplasia.
 	Recognize and describe the role of microbiome in GI disorders.
 	Identify issues associated with COVID 19 impact on Endoscopy units.
For more information, click here.

### FDA clears Pentax Medical Video ED34-i10T2 duodenoscope
The US Food and Drug Administration cleared for marketing in the U.S. the first duodenoscope with a sterile, disposable elevator component that will reduce the number of parts that need to be cleaned and disinfected (reprocessed) in between uses.
The Pentax Medical Video ED34-i10T2 model duodenoscope is intended to provide visualization and access to the upper gastrointestinal (GI) tract to treat bile duct disorders and other upper GI problems.
The FDA has previously issued communications to health care facilities about following appropriate steps for cleaning and disinfecting these devices between use. In August, the FDA released a safety communication recommending that duodenoscope manufacturers and health care facilities transition to duodenoscopes with disposable components. Disposable designs can simplify or eliminate the need for reprocessing of certain components, which may reduce between-patient duodenoscope contamination.
The FDA has previously cleared duodenoscopes with removable endcap components. This most recent clearance is the first device with a disposable elevator component — a part that has been traditionally difficult to clean and reprocess. The elevator part of the duodenoscope facilitates access to the bile and pancreatic ducts, and is used to position endoscopic instruments during the procedure.
The Pentax Medical Video Duodenoscope ED34-i10T2 is intended to be used with endoscopic devices, introduced in the patient’s mouth, to provide visualization via a video monitor of and therapeutic access to the biliary tract (liver, gall bladder and bile ducts) through the upper gastrointestinal tract. Risks of using the Pentax Medical Video Duodenoscope ED34-i10T2 include the potential for injuries, including, but not limited to, burns, electric shock, perforation, infection and bleeding.
The Pentax Medical Video Duodenoscope ED34-i10T2 was reviewed through the premarket clearance (510(k)) pathway. A 510(k) notification is a premarket submission made by device manufacturers to the FDA to demonstrate that the new device is substantially equivalent to a legally marketed predicate device. As part of the premarket clearance review, the manufacturer submitted evidence to the FDA demonstrating that the device is substantially equivalent to a predicate device.
The FDA granted clearance of the ED34-i10T2 to Pentax of America.
Source: US FOOD AND DRUG ADMINISTRATION

### Flexible Inspection Scope
Healthmark is pleased to announce the newest Flexible Inspection Scope added to their Prosys Optical Inspection product line, the FIS-006.
Designed to inspect internal channels of 1.3mm in diameter or larger, the FIS-006 is the ideal tool to visually inspect the internal channels of potentially soiled or damaged item. The flexible inspection scope is 1.18mm in diameter, equipped with a distal tip composed of a light source and camera lens at the end of a 110cm, graduated, black shaft that connects to the included control box, which allows for image capture and recording. The scope provides light, vision, magnification and the ability to document in hard-to-see lumens and crevices not visible to the unaided eye. The starter kit includes the FIS-006, the Windows PC software, USB cable, DVI to HDMI cable, and instruction book in a hard sided carrying case.
Visit www.hmark.com or call 800-521-6224 for more information.

### Latex Free Scissor Tests
Healthmark Industries is delighted to introduce the Latex Free Scissor Test to its ProSys™ Instrument Care product line. Manufactured from synthetic elastomer, the Latex Free Scissor Test is a tool to test the sharpness of scissors.
The Latex-Free Scissor Test is a 4.5-inch wide 6-yard roll that is offered in the colors of yellow or red. The yellow roll is .312 lbs., has a thickness of .007 Mil and is for testing scissor blades with lengths less than 4.5 inches. The red roll is .45 lbs., has a thickness of .010 Mil and is for testing scissor blade lengths that are greater than 4.5 inches. Simply unroll to the desired length and make a minimum of two cuts in the test material. Begin by cutting at the middle part of the blade, cutting clearly through the tip. The scissors should cut all the way through to the top of the scissor without catching or snagging.
Visit www.hmark.com or call 800-521-6224 for more information.

### Insulation Tester
Healthmark Industries is delighted to introduce the Insulation Tester with optional Bi-Polar fixture to its ProSys™ Instrument Care product line.
Designed for electrically testing electrosurgical instruments, the low frequency high voltage Insulation Tester is used to detect and locate defects such as pinholes, cracks and bare spots in the jacket or coating of laparoscopic and bi-polar electrosurgical instruments. The Insulation Tester is a handheld, portable unit that tests the insulation integrity of electrosurgical equipment for flaws in protective coatings applied over conductive instrument surfaces in order to prevent inadvertent tissue burns, which may occur during electrosurgical instrument procedures.
Manufactured with a rechargeable battery, the Insulation Tester maintains applied test voltage with a constant current source, features full test current at low voltages, limited output current for operational safety, easy to read LED Indicators, as well as LED display of alarm and battery charge.
The Insulation Tester comes with the following reusable and interchangeable accessories: ground wire with alligator clip, ring electrode, tri-hole electrode, brush electrode, saddle, and case. The Bi-Polar Fixture accessory that works in conjunction with the saddle, ground wire and brush electrode can be purchased separately. Additionally, an optional Wire Tester accessory used with an HV Red Lead Wire is available for testing wires by locating and identifying defects such as pinholes or cracks in the conductive core.
Visit www.hmark.com or call 800-521-6224 for more information.

### Glove Box Dispenser
Healthmark Industries is delighted to introduce the Glove Box Dispenser for Xtra Long Gloves (16”) to its Personal Protection Equipment product line.
Manufactured from clear PETG Plastic-Copolyester resin, the Glove Box Dispenser is designed for boxed disposable glove storage, made to withstand heavy-duty applications and handling, as well as reduce losses due to breakage.
The Glove Box Dispensers are offered in two different styles, a 0.8 lbs. single dispenser measuring 5.45 W x 16.10 H x 2.95 D Inches that accommodates one box of extended cuff gloves, and a 1.8 lbs. triple dispenser with dividers measuring 15.70 W x 16.10 H x 2.70 D Inches that holds three boxes of extended cuff gloves.
The clear design matches any décor and enables an unobstructed view of glove package information. The Glove Box Dispenser is equipped with keyholes for wall mounting, which saves counter space while keeping gloves within easy reach.
Visit www.hmark.com or call 800-521-6224 for more information.

### ENDOPRO SELECTED AS FOLIO AWARDS FINALIST
For the sixth consecutive year, EndoPro Magazine, the leading publication for endoscopy professionals, has been selected as a finalist for the Folio: Eddie & Ozzie Awards, this time chosen as a finalist three times.
EndoPro Magazine was chosen in the category of B2B Single Article—Healthcare/Medical/Nursing. The articles selected as finalists are: 
 	“Opening Doors: How Mentorships Improve Healthcare,” by Lisa Hewitt, MA (May 2021)
 	“East Meets West: Chinese Medicine and GI Health,” by Lisa Hewitt, MA (JanFeb 2021)
 	“Planning a New Endoscopy Department in 2020,” by John Fowler, AIA, EDAC, LEED AP (AugSep 2020)
Being chosen as a finalist three times in one year is just awesome, said Bill Eikost, president and publisher at 7 Toes Media, the parent company for EndoPro Magazine. “We’re honored to again be finalists for the Eddie Awards,” Eikost said. “Each of our nominees’ work is indicative of the editorial quality we strive for. It’s extremely important to our team that we provide the most relevant and helpful information possible to our hard-working readers in the endoscopy industry.”
For almost three decades, FOLIO: has been recognizing the best in B2B and consumer magazine publishing. The FOLIO: awards span print and digital media, with the Eddies honoring the best in editorial and the Ozzies honoring the best in design. The winners will be announced at the 2021 Folio: Eddie & Ozzie Awards Gala on Thursday, Oct. 14, 2021 at the Metropolitan Pavilion in New York City.
About EndoPro Magazine
EndoPro Magazine is produced by a team of publishing experts with more than 75 years of collective experience in healthcare and endoscopy publishing. EndoPro is the go-to source for timely and relevant practice and procedure guidance that endoscopy professionals need to protect their institutions, patients and fellow healthcare workers. For more information, contact Bill Eikost at (877) 519-9592 x101 or email Bill.Eikost@7ToesMedia.com. www.endopromag.com.
About Folio:
The Eddie & Ozzie Awards program is presented by Folio: the information resource that publishing executives turn to for news analysis, commentary, and thought leadership in driving business strategy, value creation and revenue growth. Folio: delivers this insight across several newsletters, social media communities, special reports and live events. For more information, visit www.Foliomag.com.

### Centra™ Disposable Biopsy Forceps
STERIS | US Endoscopy, a leader in advanced technology advancements in single-use devices for gastrointestinal practice, such as the Centra™ line, physicians will have access to a full line of safe, user-friendly biopsy forceps for endoscopy that meet their needs in all clinical situations relating to biopsy or collection of tissues for analysis, including polypectomies and other tissue acquisition procedures. The Centra™ new line of biopsy forceps from STERIS | US Endoscopy are designed specifically with physician needs and wishes in mind: a durable, dependable choice for precision, safety and ease-of-use for your physicians.
Through a newly established distribution agreement, STERIS | US Endoscopy will offer four single-use Biopsy Forceps for Endoscopy products throughout the United States. Designed for seamless compatibility with flexible endoscopes, the Centra biopsy forceps enable clinicians to obtain high-quality tissue samples for pathological evaluation. Healthcare providers have many options to select from when using these endoscopic devices in conjunction with therapeutic procedures using the cold needle variety or without either.
The Centra Disposable Biopsy Forceps for Endoscopy, from STERIS, exemplify the company’s dedication to innovation, patient safety, and clinical efficiency through the continuing development of a diverse array of products designed to provide physicians with options for the sampling of tissues and for use in the removal of polyps as well as other such tools that will assist physicians and their staff in enhancing the quality of care provided to patients while enhancing the productivity of the healthcare delivery system.
"This new line of cold biopsy products represents a significant extension of our diversified and comprehensive product offerings and further displays our commitment to providing our customers with complete solutions to meet their tissue acquisition and sampling requirements," says Tony Siracusa, Vice President and General Manager of STERIS | US Endoscopy.
With the introduction of the Centra™ disposable Biopsy Forceps for Endoscopy, STERIS continues to strengthen its leadership position in the endoscopy market, offering dependable, high-quality solutions that enhance clinical performance. For more information, visit www.usendoscopy.com.

### Dri-Scope Aid®Jet~Stream with Increased Flow
TRICOR Systems Inc. Launches Dri-Scope Aid®Jet~Stream with Increased Flow
Dri-Scope Aid®Jet~Stream Assists in the Drying of the Internal Channels of an Endoscope. 
 Elgin, IL – SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes states: “Drying the endoscope after every reprocessing cycle, both between patient procedures and before storage, is a requisite practice crucial to the prevention of bacterial transmission and nosocomial infections.” “Drying is as important to the prevention of disease transmission and nosocomial infection as cleaning and HLD.” The Dri-Scope Aid® family of products have been on the forefront of finding a solution for every facility to dry their scopes properly after high-level disinfection. “There have been multiple studies done in the past year highlighting the risk of bacterial growth that can happen if an endoscope isn’t properly dried after it comes out of an AER. The assumption that alcohol and hanging are enough, has been proven not to work,” said George Cronin, National Sales Manager. “In the recently published study, Barakat MT, Huang RJ, Banerjee S. Comparison of automated and manual drying in the eliminating residual endscope working channel fluid after reprocessing. Gastrointestinal Endoscopy (January 2019), Volume 89, Issue 1, Dr. Barakat changed the conversation from should we be drying to how are we going to dry.  They showed that constant automated flow of air, outperformed 10 minutes of high psi manual air. It is the focus of the new Dri-Scope Aid®Jet~Stream to always have automated constant/consistent flow of HEPA filtered air with repeatable results”
TRICOR Systems Inc. is excited to announce the new Dri-Scope Aid®Jet~Stream standalone system with dual timer, .1 micron HEPA-filter, and the greatest amount of airflow on the market. The dual timer allows the operator to hook up two endoscopes (all major brands) with independent start and stop times. The individual timers will help with the flow and turnaround time in the reprocessing room.
The Dri-Scope Aid®Jet~Streamunit features a daily disposable tubing assembly, and individual scope connectors, to alleviate cross-contamination concerns. The scopes are simply attached to the daily tubing assembly via the connectors, the required time is set, and the start button pressed to initiate a continuous flow of HEPA-filtered air through the scope(s), freeing the technician for other duties. Timing can be set between 1 and 99 minutes using the unit’s digital display and touchpad controls. The Dri-Scope Aid®Jet~Streamunit is compact (10.2 inches tall by 6.8 inches wide and 9.5 inches deep), and weighs only 8 pounds. It is designed for countertops, wall mount or pole mount use.
For more information on Dri-Scope Aid®Jet~Stream, call 508-423-3223, e-mail sales@driscope.com and visit www.driscope.com.
####

### GI Polypectomy – The statistics, facts & tools [Infographic]
Increased awareness of colorectal cancer has become prevalent. Many times, polyps are one of the earliest manifestations of cancer and must be removed for pathological examination. US Endoscopy provides a comprehensive line of innovative polypectomy and retrieval instruments to obtain tissue specimens during these cases.
Click the infographic below to discover more about US Endoscopy's comprehensive portfolio of polypectomy products that support accommodating a variety of needs.
For more information call 1-800-769-8226 or reach your local US Endoscopy Representative by email now by clicking HERE.

### Cancer researchers identify checkpoint target for colorectal cancer immunotherapy
Immunotherapy uses the body’s immune system to target and destroy cancer cells. Considered the future of cancer treatment, immunotherapy is less toxic than chemotherapy. Colorectal cancer is the third most common cancer among men and women, yet chemotherapy remains the standard of care as limited numbers of patients respond to current immunotherapy treatment options.
The findings published in JCI Insight could provide additional treatments for a larger number of colorectal cancer patients via a new immunotherapy pathway. Researchers identified ST2 as a novel checkpoint molecule that could help T cells become more effective.
The research is a collaboration between IU School of Medicine cancer researchers Xiongbin Lu, Vera Bradley Foundation Professor of Breast Cancer Innovation and of Medical and Molecular Genetics, and Dr. Sophie Paczesny, Nora Letzter Professor of Pediatrics and of Microbiology and Immunology.
Immune checkpoints are an essential part of the immune system with the role of preventing immune cells from destroying healthy cells. T cells are immune system cells that attack foreign invaders such as infections and can help fight cancer. But cancer is tricky, and often the tumor microenvironment creates ways to prevent T cells from attacking cancer cells by misusing several factors including the activation of checkpoint molecules.
Within the tumor microenvironment, the body’s immune system knows something is wrong and sends a stress signal such as the alarmin IL-33, which brings in immune cells called macrophages that express ST2 (the receptor for IL-33) to help. What is at first a “good” response is quickly overwhelmed and the macrophages become the enemy in fighting colon cancer.
The authors investigated using patient tumor genetic data and found that T-cell functionality, one of the key factors in fighting the cancer using the adaptive immune responses, is reduced in patients displaying high ST2 levels. Using tumor tissue samples from IU Simon Comprehensive Cancer Center tissue bank, researchers found abundant expression of ST2 in macrophages in tumor tissue samples from early to late-stage colorectal cancer.
“In all of the patient samples, we were able to identify ST2 expressing macrophages, which would potentially mean that targeting these ST2 macrophages would be relevant to the patients,” Kevin Van der Jeught said. Van der Jeught is a post-doctoral researcher in Lu’s lab and first author of this study.
In preclinical mouse models, researchers found that by targeting the ST2-expressing macrophages, they were able to slow tumor growth. By depleting these inhibitory cells, the T cells became more active in fighting cancer.
Collaboration connects cancer research interests
Research collaborator and scientist at the Herman B Wells Center for Pediatric Research, Paczesny’s previous research led to the discovery of ST2 and is the subject of her National Cancer Institute “Cancer Moonshot” grant focusing on immunotherapy for pediatric acute myeloid leukemia (AML). While leukemia and colorectal cancer are very different diseases, researchers have found commonality and collaboration in the ST2 protein.
“This research is bringing together the pathway in two different diseases,” Paczesny said.
Lu’s research focuses on cancer cell biology in diseases such as triple negative breast cancer and colorectal cancer.
“We have to develop new tools and new approaches for solid tumors, and this is the kind of collaboration we need for advancing future treatments,” Lu said. Researchers from two other institutions, the University of Maryland’s Marlene and Stewart Greenebaum Comprehensive Cancer Center and the VIB-UGent Center for Inflammation Research in Belgium, have contributed to this publication.
Researchers also are exploring combination therapy with existing immunotherapy, such as PD-1 checkpoint inhibitors, which work to boost T cells directly, while attacking ST2 on macrophage cells increased T cells by stopping the inhibitors.
“Potentially through a combination of two checkpoints at work on different immune cells, we could enhance the current response rates,” Van der Jeught said.
The researchers plan to explore these findings further and pursue the development of ST2 for cancer immunotherapy.
Additional authors with Van der Jeught, Paczesny and Lu are IU School of Medicine researchers Yifan Sun; Yuanzhang Fang; Zhuolong Zhou; Hua Jiang; Tao Yu; Jinfeng Yang; Malgorzata M Kamocka; Ka Man So; Yujing Li; Haniyeh Eyvani; George E Sandusky; and Michael Frieden; Xinna Zhang and Chi Zhang, IU Simon Comprehensive Cancer Center; Harald Braun and Rudi Beyaert, Ghent University, Ghent, Belgium; and Xiaoming He, Greenebaum Comprehensive Cancer Center, University of Maryland.
This research was supported by IU School of Medicine Strategic Research Initiative fund; NIH R01CA203737 (Lu); and NIH U01CA232491 (Paczesny). A supplemental grant application has been submitted to NCI for funding further studies in hereditary non-polyposis colorectal cancer also called Lynch syndrome.
Source: Indiana University

### Integrated Endoscopy initiates worldwide pilot launch of single-use arthroscope
Integrated Endoscopy, a medical device company pioneering the development of high-definition, low-cost single-use endoscopes for the arthroscopic surgery market, today announced it has begun the international pilot launch of its NUVIS single-use arthroscope technology via placement in centers of medical excellence around the world.
News of the international roll out comes on the heels of Integrated Endoscopy’s clearance from the Food and Drug Administration (FDA) to market NUVIS in the United States.
NUVIS is a battery-operated arthroscope designed to provide high-definition visualization via a proprietary optical design, while directly addressing key safety and sterility issues associated with traditional, reusable arthroscopes. The single-use nature of the technology provides surgeons with an affordable way to eliminate bioburden and risk of infection and disease transfer due to lapses in instrument reprocessing; eliminates the need for the traditional light source and the associated heat; and can be used on existing video systems in the marketplace.
As part of this global strategy, Integrated Endoscopy has been working with a number of key hospitals and surgeons around the world, introducing the NUVIS technology. Among the early adopters globally are various centers located in the United Kingdom, France, India, Australia and a number of locations in the US.
Source: INTEGRATED ENDOSCOPY

### Integrated Endoscopy to Demonstrate Single-Use Rigid Endoscope at Orthopaedic Sports Medicine Conference
RANCHO SANTA MARGARITA, Calif.--(BUSINESS WIRE)--
 Integrated Endoscopy, Inc., will exhibit its nuvis™Single-Use Arthroscope—the only FDA-approved single-use rigid endoscope commercially available in the United States—at the American Orthopaedic Society for Sports Medicine (AOSSM) Annual Meeting, July 7-9, 2016, in Colorado Springs, Colo. (Booth No. 118).
According to Lonnie Hoyle, CEO and Chief Technology Officer of Integrated Endoscopy, the nuvis Single-Use Arthroscope allows for safer and more cost-effective procedures. “Unlike conventional reusable endoscopes, the nuvis Arthroscope never infects a patient, never needs repairs, never contributes to OR delays, and never needs to be cleaned and sterilized,” Hoyle said.
The nuvis Single-Use Arthroscope provides many benefits over conventional reusable endoscopes, including:
 	Eradicating the risk of healthcare-associated infections due to lapses in instrument reprocessing
 	Eliminating the need for sterilization and high-level disinfection of endoscopes
 	Preventing costly OR delays and downtime by ensuring the availability of patient-ready scopes
 	Providing high-definition optics and compatibility with existing video systems
 	Offering a lightweight scope with an easy-to-use design that eliminates a bulky cable, making it easier on surgeons during procedures
More than 4 million knee arthroscopies are performed worldwide each year, many of them involving sports-related injuries. “Over time, arthroscopes get damaged and degraded due to frequent use, handling, and reprocessing,” said Grady L. Jeter, M.D., founder of the Arthroscopy & Sports Medicine Clinic in San Jose, Calif. “With the introduction of the nuvis Arthroscope, surgeons now can have the optical quality of a brand new endoscope for every procedure, and patients can be assured of a sterile scope free of the potential for infection transmission.”
The nuvis Arthroscope is designed with high-definition optics and an innovative LED light source, eliminating the need for expensive xenon light bulbs and fragile fiber optic bundles. Its patented design features only 12 molded-glass lenses compared to the dozens of expensive ground-glass lenses needed with conventional reusable arthroscopes.
About Integrated Endoscopy
Integrated Endoscopy, Inc., is a pioneer in the development of high-quality, low-cost single-use rigid endoscopes. The company’s intellectual property portfolio includes nearly 20 patents in the United States, Europe, Japan, Australia, and Canada covering the lens system design, LED lighting systems in a rigid endoscope, and high-quality molded glass lenses that are at the core of its cutting-edge devices. This strong patent position makes Integrated Endoscopy uniquely positioned to be the market leader and sole provider of single-use rigid endoscopes. Integrated Endoscopy is a privately held company with headquarters and manufacturing facilities in Rancho Santa Margarita, Calif. For more information, visit www.iescope.com.
Note to editors: For more information, or to request photos and video of the nuvis Single-Use Arthroscope, contact Barbara Sullivan at bsullivan@sullivanpr.com or 714/374-6174.
View source version on businesswire.com: http://www.businesswire.com/news/home/20160706005295/en/
Contact:
Sullivan & Associates
Barbara Sullivan, 714/374-6174
bsullivan@sullivanpr.com

### Fantastic Voyage
In the somewhat cheesy 1966 film, Fantastic Voyage, a miniaturized submarine (likely most notable for having Raquel Welch among its crew) undertakes a dangerous mission: to cruise through the body of its designer in order to destroy a life-threatening blood clot in his brain.
The special effects were a little more sophisticated in 1987’s quasi-remake, Innerspace, in which Dennis Quaid pilots a microscopic pod around in Martin Short’s innards, even if the dialogue was not. And then there was the 2001 animated effort, Osmosis Jones, a bit of a box-office bomb despite a voice cast that included Chris Rock, Bill Murray, David Hyde Pierce, Molly Shannon, and Laurence Fishburne, playing interior anatomical investigation for laughs.
One thing is obvious: the notion of exploring a body from the inside, Jules Verne-style, isn’t going away.
We’re getting closer all the time to being able to do it, too. Maybe not with miniaturized humans on board, but we’ve now got the next best thing: a small, smart, sophisticated capsule endoscope (CE) which can be gently introduced to the digestive tract to take a cruise, snap some photos, and grab a few souvenirs along the way.
Capsule endoscopes have been in use in human medicine for about a decade now. Of course, we’ve had ‘regular’ endoscopes for even longer than that – the kind where a cable is snaked down the eosophagus and examines as far as it will go – but they have limitations. Even in the human gastrointestinal tract (GI), there are limits to how far we can explore with a conventional endoscope, leaving much of the twisty, turny small intestine out of reach.
A capsule endoscope, by contrast, can traverse the digestive system tetherless and fancy free, shoved ever onward by peristalsis, the natural rhythm of contractions that moves food from stomach to intestines and thence to elimination. In humans, the tiny capsules, averaging about 1 cm by 2.5 cm in size (depending on the manufacturer) are proving useful in detecting otherwise-hard-to-diagnose things such as lesions, tumours, Crohn’s and celiac disease, and mystery bleeding in the small intestine. There have been over a thousand peer-reviewed articles published since the early 2000s, all of which have concluded that capsule endoscopy is non-invasive and safe (but not, so far, re-useable).
It was only a matter of time before CE started being applied to the equine digestive tract. Conventional endoscopy is limited by the length of the ‘scope (usually somewhere between 2.2 and 2.5 metres long) – which isn’t that useful when you’re talking about a mass of tubes with a total length of 24 to 30 metres.
The sheer length and mass of the equine GI tract, combined with the way it’s shielded by thick walls of abdominal muscle, also make other diagnostic methods problematic. Ultrasound can’t penetrate the abdominal wall and the ribcage all that well, and MRI and CT have similar limitations. The conventional approach, rectal palpation, also only allows access to the last 30 to 40 per cent of the GI tract. Neither the stomach, the proximal duodenum, nor any part of the small intestine can be explored that way.
So while conventional endoscopes have had good success in illuminating gastric ulcers – and if inserted at the other end, can provide a view of the first metre or two of the large intestine – the small intestine remains a “black box”, according to Diane Gibbard, MS, who in September 2015 completed a Masters’ degree at the University of Guelph by presenting her thesis on the applications of capsule endoscopy in horses.
Her desire to investigate CE – which had previously only been applied on the veterinary side in a scant few studies on dogs and pigs – stemmed from personal experience: her first horse was suffering intermittent bouts of mild colic which defied diagnosis. Gibbard’s veterinarian suggested they try capsule endoscopy, which he had used experimentally once before – but unfortunately, the trial “failed miserably”, she says. “I thought, there has to be a way to make this work in horses,” so she approached her faculty advisor, Dr. Jeff Thomason, with the idea.
Gibbard began with one of the capsule endoscope models popular in human medicine, MiroCam©, and worked with the company’s engineers to adapt the technology for use in horses. Because of the sheer size of the patient, the capsule needed to have enhanced signal strength with which to send its images to a series of electrodes placed on the horse’s skin. Initially, those electrodes – nine in all – were taped to the skin as they are with humans, but Gibbard’s team soon discovered that sub-dermal electrodes did a better job of picking up the signal through a horse’s thick abdominal walls. Even then, the signal strength waxed and waned, and clear images only got transmitted when it surpassed 85 per cent. Through four trials each on two standardbred mares, Gibbard continued to make modifications to both the equipment and the methodology to improve the chances of success.
“In the final trial, the image transmission was much better. It’s very promising that we got such high-quality images… we saw peristalsis in action, we saw sites of inflammation, and one thing we didn’t expect at all, was clear images of parasites like tapeworms and pinworms. We got parasitologist Andrew Peregrine (University of Guelph) involved and he was over the moon, because those were the first clear images he’d ever seen of a live internal parasite ‘swimming’ in its natural environment.
“Just ‘unlocking’ the small intestine for the first time, was fascinating to me. Every time I watch the videos of the contraction and expansion that comes with peristalsis, I’m in awe.”
There were, of course, frustrations in using a technology adapted from human use. “A lot of the time, the signal transmission wasn’t good enough to get much of anything … and often when we did get images, they were partially or fully obscured by residual food particles in the GI tract, despite a 12 hour fasting protocol,” Gibbard says. “We think that a 24 fast might work better in future, but we have to balance that with compromising peristalsis, particularly because we also used sedation while introducing the capsule with a nasogastric tube. Most sedatives also interfere with peristalsis.
“It would also be great to know which leads are picking up the signal as the capsule makes its way through the gut. That would help us optimize the placement of the electrodes. We based their placement on human medicine, but it’s possible something else would work better for horses. Right now, we can’t tell exactly where in the small intestine the capsule actually is when a signal is transmitted, and that would be helpful in the identification of the images.”
Battery life is also an issue. The MiroCam © model used in Gibbard’s study remained active for about 12 hours, which with normal peristalsis is enough for it to scan most or all of the small intestine, she said. That peristalsis was encouraged with fluid boluses throughout the 12-hour period, and regular feeding of soaked hay cubes.
All told, both mares experienced minimal stress while having miniature cameras cruise through their guts, and recovered without incident. Though the team searched (and one mare was euthanized and her GI tract thoroughly explored afterwards), none of the eight capsules was ever recovered, though Gibbard suspects they probably passed out of the mares beyond the seven-day period in which their manure was collected and searched.
Gibbard’s conclusion was that CE is not ready for commercial veterinary use just yet – but it’s close. “It’s quite non-invasive, so I could see it being used on-farm in future,” she says. “I’m guessing at this point, but it would probably end up costing somewhere in the $2,000 to $3,000 range – so, not something you would use every day, but considerably cheaper than colic surgery.”
As for next steps, Gibbard would like to try CE on a pony. “One of our test horses was quite a bit smaller than the other, and we consistently got better results with the smaller mare, so size may matter,” she says. “I would also like to increase the fasting protocol to 24 hours, to see how it affects image capture.
“I think the potential for (CE to perform) tissue biopsy is really interesting. That’s something that’s starting to be explored in human medicine, along with capsule endoscopes which could be controlled and ‘steered’ so that you can take more detailed images of a particular area, for example, or even go back to get a better look at something suspicious.”
Potential applications of CE in horses
• gastric ulcers
• Lawsonia bacterial infections
• intestinal ulcers
• tumours, including lymphosarcoma, squamous cell 
 carcinoma, and adenacarcinoma
• some forms of colic (not impactions or torsions)
• malabsorption syndrome
• sand accumulation in the gut
• parasitism and associated inflammation and damage
• tissue biopsy
by Karen Briggs
Originally appears in Harness Racing Update

### Olympus, Pentax, Karl Storz Lead Shift to Popular Flexible Videoscopes in U.S. Ear, Nose and Throat Endoscope Market
June 14, 2016 12:48 ET
In 2015, There Were Nearly 6 Million Ear, Nose and Throat (ENT) Procedures Performed in the United States; the Total Market for ENT Endoscopes Was Valued at Over $75 Million
VANCOUVER, BC--(Marketwired - June 14, 2016) - According to a new series of reports on the U.S. market for ENT and bronchoscopic devices by iData Research (www.idataresearch.com), nose related procedures represented approximately 50% of the total ENT treatments in the United States. A large percentage of nose procedures are related to chronic sinusitis treatments. As many ENT procedures are elective, increased medical coverage and rising expendable incomes are helping the market grow. The continued shift to videoscopes and their higher average selling prices (ASP) will help maintain the ENT endoscope market and provide growth over the forecast period. The market for ENT endoscopes includes rigid scopes and flexible scopes.
The flexible scopes segment represents over 60% of the total ENT endoscope market. This market includes fiber optic and video flexible scopes. Rigid scopes have been losing market share over the past few years due to the increased preference towards flexible scopes. Although rigid scopes are not as widely applicable as flexible scopes, they are still a requirement in all ENT surgeons' portfolios.
"The market value of endoscopes will experience limited growth and potential contraction as hospitals begin utilizing refurbished scopes in an effort to save costs," explains Dr. Kamran Zamanian, CEO of iData. "Some manufacturers have reported as much as 50% of their unit sales come from the refurbished market."
Although rigid scopes do not cover the range of procedures that flexible scopes do, there is still a significant market for these devices. The backbone of this market is the replacement of existing rigid scopes. Due to this replacement necessity, annual rigid scope unit sales are expected to exceed 13,500 for the foreseeable future. However, the increased prevalence of refurbished rigid scopes may have a negative impact on the overall market value, if not on the unit sales. Additionally, rigid scopes will be experiencing decreasing ASPs over the forecast period due to increased commoditization.
Olympus currently maintains the largest market share within the ENT endoscope market. This position is largely due to its dominance in the flexible endoscope market. Olympus is particularly strong within the growing flexible videoscope market, maintaining a majority of this market share through its ENF® and VISERA® product lines. Karl Storz is a close second in the ENT endoscope market. The majority of this is due to its strength in the rigid endoscope market. Additionally, Karl Storz will continue gaining market share through its popular HOPKINS® product line.
Pentax maintains a large share in the flexible endoscope market and is also well positioned through its offering of an ultrasound gastroscope in the EG line. Additional competitors in the ENT endoscope market include Cogentix, Richard Wolf, Teleflex, Acteon, BR Surgical and Ecleris, among others.
For Further Information
More on the ENT Endoscope market in the U.S. can be found in a report suite published by iData Research entitled the U.S. Market for ENT and Bronchoscopic Devices Report Suite. The suite covers reports on the following markets: ENT Endoscopes, ENT Powered Instruments, ENT Hand Instruments, ENT Radiofrequency Devices, Balloon Sinus Dilation Devices, Bronchoscopes, Bronchoscope Hand Instruments, Bronchial Stents, Bronchial Forceps, Transbronchial Aspiration Needles, and Foreign Body Removal Devices.
Reports also provide a comprehensive analysis including units sold, procedure numbers, market value, forecasts, as well as detailed competitive market shares and analysis of major players' success strategies in each market and segment. To find out more about ENT and Bronchoscopic device market data or procedure data, register online or email us at info@idataresearch.net for a U.S. Market for ENT and Bronchoscopic Devices Report Suite report series brochure and synopsis.
About iData Research
iData Research (www.idataresearch.com) is an international market research and consulting group focused on providing market intelligence for medical device and pharmaceutical companies. iData covers research in: Laparoscopy, Urology, Gynecology, Vascular Access, Endoscopy, Interventional Cardiology, Cardiac Surgery, Cardiac Rhythm Management, Electrophysiology, Ultrasound, X-Ray Imaging, Diagnostic Imaging, Oncology, Spinal Implants and VCF, Spinal MIS, Orthopedic Soft Tissue Repair and Regeneration, Orthopedic Trauma, Large & Small Joints, Anesthesiology, Wound Management, Orthopedics, Ophthalmics, Dental, and more.

### Duodenoscopes With Disposable Caps Have Less Microbial Contamination
According to a study published in JAMA Internal Medicine, using duodenoscopes with disposable elevator caps during endoscopic retrograde cholangiopancreatography (ERCP) led to lower rates of contamination following high-level disinfection, compared to standard scope designs. The disposable caps did not alter the performance and safety of the procedure, the randomized ICECAP trial showed.
The study, “Effect of Disposable Elevator Cap Duodenoscopes on Persistent Microbial Contamination and Technical Performance of Endoscopic Retrograde Cholangiopancreatography,” answered the following question: “In patients undergoing ERCP, do duodenoscopes with disposable elevator caps (1) reduce contamination rates after high-level disinfection and/or (2) maintain technical performance of the procedure compared with duodenoscopes with standard designs?”
The study included 518 patients undergoing ERCP of various procedural complexity, duodenoscopes with disposable caps reduced persistent microbial contamination (relative risk, 0.34), with no differences in performance (technical success, 94.6% vs 90.7%) and safety outcomes.
The trial was conducted at two tertiary ERCP centers in Canada. All patients 18 years and older undergoing ERCP for any indication were eligible.
Researchers found that disposable elevator cap duodenoscopes exhibited reduced contamination following high-level disinfection compared with standard scope designs, without affecting technical performance and safety of ERCP.

### Improving key diagnostic measures for gastrointestinal disorders
With no laboratory test available to diagnose functional gastrointestinal disorders, proper diagnostic criteria are critical for clinicians to make an accurate determination of what ails their patients.
Several University of North Carolina School of Medicine researchers played a key role in crafting diagnostic criteria and patient questionnaires for the Rome Foundation, an international nonprofit aimed at improving the lives of the millions of people suffering from functional GI disorders (FGIDs), while developing and legitimizing the field of FGIDs through science and research.
William E. Whitehead, PhD, professor of medicine in the division of gastroenterology and hepatology and director of the UNC Center for Functional GI and Motility Disorders has served on the Rome Foundation Board since its inception.
Functional GI disorders don't have a clear, organic cause, and cannot be caught on any lab test, Whitehead said.
If a person has a functional GI disorder, "the gut is healthy, but it functions differently," said Miranda van Tilburg, PhD, an associate professor of medicine in the division of gastroenterology and hepatology, who contributed to the new diagnostic criteria. "We have to [diagnosis] based on symptoms...You could compare it to a [mental health diagnosis] in a way. For example, you cannot do a blood test for depression. You have to ask people questions and so we have to do the same thing for these disorders."
As researchers have learned more about these disorders, it has been necessary to update the diagnostic tools available to clinicians.
"The diagnostic criteria for functional GI and some motility disorders have gone through four editions, so the one that's just been released -- Rome IV -- is being published about 10 years after Rome III. It tries to incorporate the research that's been done since that time," Whitehead said.
Whitehead, along with van Tilburg, Douglas Drossman, MD, and Olafur Palsson, PsyD, played a critical role in the amended diagnostic criteria and patient questionnaires published in Rome IV. Drossman, who currently serves as president of the Rome Foundation, is an emeritus co-director of the UNC Center for Functional GI and Motility Disorders and adjunct professor of medicine and psychiatry. Palsson is a professor of medicine in the division of gastroenterology and hepatology and a member of the UNC Center for Functional GI and Motility Disorders.
"Our job was, in part, to develop a diagnostic questionnaire based on criteria that committees of experts developed for making these diagnoses," Whitehead said. "Developing these materials was a multi-year process to be sure it was understandable and translatable to other languages and that it was valid in the sense that it agrees with the diagnoses of expert clinicians."
"This year, there was a lot of time spent on the adult questionnaire," van Tilburg said -"revamping the answer categories so that they were more sensitive and better able to catch the symptoms we needed to catch."
A commonly diagnosed disorder that underwent diagnostic changes is Irritable Bowel Syndrome (IBS), which affects an estimated six percent of the population -- or about 19 million people in the United States. Before the new diagnostic criteria, an estimated 11 percent of the population was thought to have IBS or at least presented symptoms that mirrored IBS, Whitehead said.
"In the adult criteria, [IBS] used to be diagnosed based on the presence of abdominal pain or discomfort at least three times a month," Whitehead said. "The new criteria require that there be pain -- so discomfort doesn't qualify -- and it requires that it occur at least once a week on average. There are also some changes in the way that sub-types of IBS are diagnosed, which often dictate what treatment is appropriate -- what drugs, especially."
On the pediatric front, there are new categories of disorders that weren't previously included at all that are now recognized, such as functional nausea and functional vomiting, van Tilburg said. New adult diagnoses included cannabinoid-induced nausea and opiate-induced constipation.
Van Tilburg also played an important role in revising the child/adolescent diagnostic criteria. She was on a committee of six worldwide experts tasked to revise these criteria. Because of the new criteria, between Rome III and Rome IV, the prevalence of IBS in children/adolescents has increased from 2.8 percent to 5 percent. Prevalence of any functional GI disorder increased only slightly; these disorders affect nearly one in four children.
Story Source:
The above post is reprinted from materials provided by University of North Carolina Health Care. Note: Materials may be edited for content and length.
University of North Carolina Health Care. (2016, June 21). Improving key diagnostic measures for gastrointestinal disorders. ScienceDaily. Retrieved June 28, 2016 from www.sciencedaily.com/releases/2016/06/160621155043.htm

### Safety First: Mitigating Risks in the Endoscopy Suite
By Sue Ohme, RN, BSN
One of the most well-known ethical principles that guides nursing care is non-maleficence, or the intent not to harm. In a position statement for the Nursing Code of Ethics, the American Nurses Association states that “nonmaleficence in nursing requires the provision of safe, effective, high-quality care.” To act in our patients’ best interest, it is crucial that we have a thorough understanding of risks and benefits for the procedure being performed and do everything possible to minimize harm.
As nurses, we play a pivotal role in advocating for patient safety. In an endoscopy unit, our patients often come to us feeling vulnerable and nervous before a procedure. Implementing endoscopy nursing interventions allows us to provide the highest level of care, ensuring patient comfort and safety. We can have a powerful impact on delivering the best possible health outcomes by adhering to the ethical principles of beneficence and non-maleficence. The ANA refers to beneficence as promoting good and ensuring that the patient’s best interest drives care. We can achieve this by providing compassionate care, following essential endoscopy nursing interventions, and taking the time to listen to our patients, address their concerns, and provide education about the procedure or their condition.
To ensure patient safety during an endoscopic procedure, the nurse’s role encompasses a variety of checks and balances throughout the pre-procedure, intra-op, and recovery phases, allowing the opportunity to proactively mitigate risk at each stage. While training new staff members or learning a new role, nurses can often be found hyper-focusing on the required documentation portion of the electronic medical record, unintentionally ignoring the fundamentals of the procedure and the associated risks involved. Exploring each phase of care in greater detail can reveal areas that allow for improvement and reduced risk.
In preop, during patient intake, it is crucial to not only focus on the required screening questions but also to assess your patient’s overall physiological status. This is especially true in situations where the nurse has a greater responsibility to the patient’s well-being, as with moderate sedation cases where anesthesia is not actively involved. Effective endoscopy nursing interventions at this stage include thorough patient assessments, risk factor evaluations, and ensuring proper sedation protocols are followed.
The Society of Gastroenterology Nurses and Associates (SGNA) has an incredibly informative website. The section titled “Practice Resources and GI Nurse Sedation” provides a wealth of information on nurse sedation during an endoscopic procedure. SGNA states that cardiopulmonary events related to sedation are the most frequent cause of GI endoscopy–related morbidity and mortality (SGNA, n.d.). In your preassessment of the patient, think about comorbidities and other risk factors that could impact your ability to adequately and safely sedate the patient for the procedure. Utilizing evidence-based endoscopy nursing interventions ensures that sedation practices align with safety standards and minimize potential complications. The American Society of Anesthesiologists has a classification system that can help predict the perioperative risk based on a patient’s medical comorbidities.
Score
Description
I
Normal healthy patient
II
Patient with mild systemic disease
III
Patient with severe systemic disease
IV
Patient with severe, constantly life-threatening disease
V
Moribund patient who is not expected to survive without operation
VI
Brain-dead patient (organ donor)
*ASA Scoring Table: Scores assigned based on comorbidities in pre-sedation screening assessment.
SGNA recommends considering anesthesia involvement for patients with ASA scores of III or greater, along with patients who have difficult airways, are at a high risk for aspiration, and have reduced tolerance or paradoxical reactions to standard sedatives (SGNA, n.d.).
In the procedure room, the level of a nurse’s experience can have a profound impact on adverse events. A study done at the University of North Carolina found that if you do not have an experienced nurse in the procedure room during a colonoscopy, the risk of immediate procedural complications goes up tenfold. In addition to adverse events, this study also found that the presence of inexperienced nurses led to prolonged procedural times and decreased cecal intubation rates for screening colonoscopies (Dellon ES et al., 2009). Having an experienced nurse in the endoscopy suite can go a long way toward mitigating potential adverse outcomes.
Other considerations during a moderate sedation case include adding capnography monitoring and making sure there is clear, two-way communication between the nurse and the endoscopist. Capnography measures carbon dioxide concentrations during respiration and can help to quickly detect hypoventilation before pulse oximetry indicates oxygen desaturation. This allows the nurse to initiate appropriate and timely endoscopy nursing interventions by recognizing potential problems earlier. Communication between the nurse and endoscopist is crucial to ensure patient safety and positive outcomes. The nurse should feel empowered to bring any potential concerns to the attention of the team.
Maintaining basic safety measures during the case allows the nurse to mitigate potential risks, especially when cautery is involved. Safe practices during electrocautery include knowledge surrounding proper grounding pad placement, among other considerations. The Association of Perioperative Nurses states that patient skin injuries at the dispersive electrode site are the most frequently reported electrosurgical incidents (DiNobile, 2022). Grounding pads should be applied to a muscular, well-vascularized area; the optimum site for colonoscopies is the flank. The long end of the pad should face the surgical site, which gives the current the largest possible area to spread out and be safely dispersed. Following evidence-based endoscopy nursing interventions ensures proper pad placement, minimizing risks, and enhancing patient safety. The pad placement site should be smooth, clean, dry, and free of scar tissue. Avoid placing the pad in a position that directs the surgical current path through a metal implant. Additionally, maintaining strict infection control protocols, including the use of an endoscope sterilization machine, is crucial in preventing cross-contamination and ensuring patient safety during procedures.
You also want to avoid placing the grounding pad over a tattoo, which may contain metallic dyes that can cause burns. The AORN Perioperative Standards and Recommended Practices for Electrosurgery is a great resource for guidelines and further information regarding safe practices surrounding grounding pad placement. Remember, site selection by an experienced nurse or tech can play a pivotal role in burn prevention and patient safety.
Another consideration while intra-op is the application of abdominal pressure to reduce scope-looping and to assist the colonoscope with its advancement forward within the colon. To avoid potential complications such as perforation or bleeding, it is important to apply even pressure over as broad an area as possible, avoiding any pinpoint, forceful pressure that may be applied, such as when using the knuckles or elbow. Additionally, ensuring proper equipment hygiene with an endoscope sterilization machine is essential to maintaining patient safety and preventing infections during procedures.
For example, the Prechel technique encourages using the flat surfaces of the caregiver’s forearm and the patient’s weight to apply the splinting pressure needed to support cecal canulation, while the patient is in the left lateral position. An alternative option to using the useful forearm, especially on obese patients, is placing a positioning wedge under the patient’s abdomen and having the patient roll onto the wedge while rolling onto their left side; thereby applying uniform abdominal pressure throughout the procedure, increasing canulation success rates.
A recent study found that when compared to using no device, using a positioning wedge under the abdomen eliminated the need for abdominal pressure for two-thirds of obese colonoscopy patients (Fetzer, 2020). Incorporating endoscopy nursing interventions, such as proper patient positioning, can significantly improve procedural success and patient comfort. It is important to communicate with the recovery nurse if the case requires a significant amount of abdominal pressure to reach the cecum and to be aware of early signs and symptoms of perforation, which include severe nausea, abdominal pain, and distention.
In recovery, post-sedation monitoring is essential to ensure the patient has returned to an acceptable level of functioning before being discharged home. Using a standardized scoring system, such as the Aldrete or Modified Aldrete score, will allow the nurse to determine if a patient is safe for discharge. This is the time to evaluate for potential procedural complications. Implementing effective endoscopy nursing interventions during the recovery phase, such as continuous monitoring, patient education, and early detection of adverse events, helps promote patient safety and optimal outcomes. By understanding what is happening in the procedure room as well as reviewing the patient’s pre-existing conditions, we can anticipate potential complications.
As nurses in a busy endoscopy unit, we are trusted with a range of roles and responsibilities that can often be daunting. By adhering to the ethical principles of beneficence and non-maleficence, we can provide patient-centric care that ensures the best possible outcomes while maintaining the trust and safety of the patients we serve. Proper use of advanced medical equipment, such as an endoscope sterilization machine, plays a crucial role in infection control, ensuring that each procedure is conducted with the highest standards of hygiene and patient safety.
Sue Ohme, RN, BSN, works at Swedish Medical Center in Issaquah, Washington. She graduated from Pacific Lutheran University with her BSN in 2013. Immediately after nursing school, she worked in a community hospital’s progressive care unit, which allowed her to hone her cardiac and respiratory skills. Ohme has worked at Swedish Medical Center since 2015, first as an emergency room RN, then switching to endoscopy in 2021. She’s been cross-trained in ECT and PPACU and is an active member of her unit’s shared-leadership committee. Before nursing, Ohme graduated with a BS in biology and worked as a chemist.
References
 	Asa Physical Status Classification System - American Society of ... (2020, December 13). Retrieved March 13, 2023, from https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system
 	Dellon ES;Lippmann QK;Galanko JA;Sandler RS;Shaheen NJ; (2009, August). Effect of GI endoscopy nurse experience on screening colonoscopy outcomes. Gastrointestinal endoscopy. Retrieved March 12, 2023, from https://pubmed.ncbi.nlm.nih.gov/19500788/
 	DiNobile, C. (2022, November 4). Take our electrosurgery safety quiz. Outpatient Surgery Magazine. Retrieved March 19, 2023, from https://www.aorn.org/outpatient-surgery/article/2009-February-take-our-electrosurgery-safety-quiz
 	Fetzer, S. J. (2020). Application of a Positioning Wedge During Colonoscopy of Obese Patients to Mitigate Nurse Pain. AAOHN Journal, 68(7), 320–324. https://doi.org/10.1177/2165079920904743
 	GI nurse sedation. SGNA. (n.d.). Retrieved March 12, 2023, from https://www.sgna.org/Practice-Resources/GI-Nurse-Sedation
 	Why ethics in nursing matters: Ethical principles in nursing. ANA. (2023, February 17). Retrieved March 12, 2023, from https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/why-ethics-in-nursing-matters/

### When doctors and nurses can disclose and discuss errors, hospital mortality rates decline
The diffusion of a culture of openness in hospitals is associated with lower hospital mortality, according to a study conducted among 137 acute trusts in England by Veronica Toffolutti (Bocconi University and London School of Hygiene & Tropical Medicine) and David Stuckler (Bocconi University) published in Health Affairs.
Hospital openness, defined as "an environment in which staff freely speak up if they see something that may negatively affect a patient and feel free to question those with more authority," has already been linked with many positive outcomes, such as better patient safety or better understanding of patients' care goals, but this is the first time that an association with mortality rates has been demonstrated.
The authors linked data on hospital mortality rates with hospital openness scores for 137 acute trusts in England in the period 2012-14. They used the Summary Hospital-level Mortality Indicator (SHMI) as a measure of mortality and designed a standardized openness indicator that draws on staff surveys from the Picker Institute Europe's National Staff Survey. (An acute trust is an organization within the English NHS that includes one or more hospitals providing secondary health care services).
Two positive findings were highlighted in the study. First, fostering openness translates into lower mortality rates: a one-point increase in the standardized openness score is associated with a 6.48 percent decrease in hospital mortality rates. Second, as far England is concerned, openness is increasing: the score was 13.63 in 2012 and 16.49 in 2014.
Part of the effect is due to the higher responsiveness of open organizations: the correlation between the standardized openness indicator and the percentage of staff reporting that the trust took action after an error is very high (0.84).
"The single component of our indicator that most affects mortality rates is good hospital procedures for reporting errors, near misses, and incidents," Toffolutti said. "Moreover, as defensive medical practices could stymie openness, preventing the blame game that holds practitioners responsible for errors, in favor of institutional responsibility, could help the shift to a greater culture of openness."
The results show that greater openness in the English NHS corresponds to improved health care quality and suggests that the reforms undertaken since 2016 (in part as a consequence of the results of the 2013 Francis Inquiry) are a step in the right direction.
Source: Bocconi University

### New Ventaire™ Scope Drying and Tracking Cabinet
InnerSpace, a Solaire Medical Company, today announced the launch of its Ventaire Scope Drying and Tracking Cabinet. Ventaire provides real-time tracking capabilities, online scope monitoring and features an automated system that continuously delivers HEPA-filtered pressurized air into endoscope channels to keep scopes dry and avoid reprocessing.
In addition to displaying real-time tracking information like storage durations and expiration times, the Ventaire Scope Drying and Tracking Cabinet generates a report detailing all scope activity.
"Effectively drying and storing endoscopes is critical for ensuring hygiene, prohibiting bacterial growth and potentially lowering infection rates," said Ben Barber, president, InnerSpace. "Ventaire strengthens our position as a leader in medical storage by expanding the capabilities of our scope cabinet offering while providing significant value for healthcare systems that need to ensure infection prevention and meet industry standards."
In addition to the scope drying and tracking cabinet, the Ventaire product line includes a scope tracking cabinet, retrofit scope drying and tracking cabinet and tracking units that can be field-installed in InnerSpace Evolve scope cabinets.
"Our Ventaire scope tracking cabinet offers a cost-effective and efficient way to track scope storage," Barber said.
A unique aspect of the Ventaire product line is that it allows users to monitor cabinet activity and update scope inventory remotely through the InnerSpace Smart Solutions website.
The Ventaire Scope Drying and Tracking Cabinet system meets the 2021 Multisociety Task Force Scope Storage and Drying Guidelines and works with all major endoscope brands. For more information, please visit www.innerspacehealthcare.com.

### Beard Nets
Healthmark Industries is excited to introduce the Beard Net to its Personal Protection Equipment Accessory Line. Manufactured from polypropylene, the single-use Beard Net is latex-free and designed to cover beards to limit as a source of possible contamination. The Beard Net is a one size fits most, colored white and available for purchase in a pack of one hundred. Visit www.hmark.com or call 800-521-6224 for more information. 

### New Anti-Fatigue Mat
Healthmark Industries is delighted to introduce the Anti-Fatigue Mat to its Personal Protection Equipment (PPE) product line. 
Manufactured from energy-return polyurethane foam, the black 0.75-Inch thick Anti-Fatigue Mat is designed for healthcare workers in reprocessing areas to help reduce fatigue and discomfort from standing for long hours. Eco-friendly and providing ergonomic comfort, the Anti-Fatigue Mat has a stain and puncture-resistant surface to prevent absorption of dirt and water, a beveled edge at 18 degrees to reduce tripping potential, matte textured top surface to provide optimum friction and anti-microbial properties for added protection. 
The easy-to-clean slip-resistant Anti-Fatigue Mat is equipped with a high-traction bottom surface certified by the National Floor Safety Institute and is offered in the following sizes: 20 x 32 Inches, 24 x 36 Inches, and 20 x 48 Inches. For more information visit: www.hmark.com or call 800-521-6224.

### New Shaver Leak Tester
Healthmark Industries is excited to announce the addition of the Shaver Leak Tester to its ProSys™ Instrument Care product line. 
The Shaver Leak Tester is specifically designed for pressure testing arthroscopic shavers in order to help identify leaks caused by failing seals. These seals degrade over time from repeated use and processing. The Shaver Leak Tester includes both a hand pump to apply pressure and a testing stop, made from polypropylene to create a temporarily closed system within the fluid pathway of the shaver to pressure test for leaks. Utilizing positive pressure, the user can determine if the internal seals are failing and the shaver needs to be sent out for repair. 
The Shaver Leak Tester helps in reducing the potential for cross-contamination, damage and costly repairs that result from using a shaver with leaks. 
 Visit www.hmark.com for more information. 

### Adherence to oral diabetes drugs may improve survival in diabetics with colorectal cancer
Among patients with both colorectal cancer and diabetes in Korea, those who had a high adherence to their oral diabetes medication had a significantly reduced risk of overall mortality compared with those with lower adherence.
Findings are published in the journal Cancer Epidemiology, Biomarkers & Prevention, a journal of the American Association for Cancer Research.
"It is estimated that only 60 percent of those with diabetes are taking their anti-diabetic medications as directed," said senior author Aesun Shin, MD, PhD, professor in the Department of Preventive Medicine at Seoul National University College of Medicine. "We wanted to study whether adhering to diabetes medications has an impact on survival among patients with colorectal cancer."
The association between diabetes and increased incidence of colorectal cancer is well established, noted first author Sunho Choe, MD, resident physician in the Department of Preventive Medicine at Seoul National University College of Medicine Further, the use of the antidiabetic medication metformin has been repeatedly shown to improve colorectal cancer survival among those with diabetes, he said.
"However, it is estimated that the majority of patients take additional anti-diabetic medications along with metformin, and how the combination of these medications affects the prognosis of colorectal cancer remains under-explored," he added.
"We wanted to improve upon prior studies that evaluated how the use of metformin alone impacted colorectal cancer outcomes," Shin said. "To that end, we compared survival outcomes among colorectal cancer patients who had different levels of adherence to all of their prescribed oral antidiabetics."
To conduct this retrospective cohort study, the researchers used information from the National Health Information Database, which has claims data for those who have national health insurance in Korea, from 2002 to 2016. Individuals who had diabetes and were diagnosed with colorectal cancer in this time frame were included in the study, resulting in a total study population of 33,841 participants. Patients were followed for an average of 4.7 years.
To estimate patients' adherence to their oral antidiabetic medications, the researchers used prescription data to calculate the patients' proportion of days covered (PDC), which is defined as the number of days with medications on hand divided by the number of days in a specified time interval. Adherence to prescribed injectable medications, including insulin, was not measured. The researchers categorized oral medication adherence into two groups for comparison: patients with high adherence had a PDC of at least 80 percent, while patients with low adherence had a PDC of less than 80 percent.
Overall, the researchers found that more than 80 percent of patients were taking more than one oral anti-diabetic medication. Further, less than 23 percent of patients were in the high-adherence category. Compared with patients with high adherence, those with low adherence to their oral anti-diabetic medication had a nearly 20 percent increase in their risk of overall mortality, in both crude and adjusted models. High adherence to oral anti-diabetic medication was found to have a protective effect for all colorectal cancer subgroups, with the most pronounced effect observed among patients with distal colon cancer.
"Based on our data, less than 25 percent of patients were taking their diabetes medications as prescribed, suggesting that over 75 percent of diabetic patients with colorectal cancer could benefit by adhering to these prescriptions," said Shin.
The researchers did not have access to some clinical information, including cancer stage, which is an important factor in comparing prognoses between different groups. In lieu of cancer stage, the researchers stratified the study population based on type of cancer treatment received. Patients who had early-stage disease likely received surgery alone, while patients with late-stage disease likely received palliative therapy, such as chemotherapy or radiotherapy without surgery, Shin explained.
The researchers found that patients who received surgery, surgery plus radiotherapy, or surgery plus chemotherapy had a protective benefit if they had high adherence to oral anti-diabetic medications. Patients who received surgery with both radiotherapy and chemotherapy or patients who received radiotherapy or chemotherapy without surgery did not have a protective benefit even if they had a high adherence.
Source: American Association for Cancer Research

### New UVC LED Box
Healthmark Industries is delighted to introduce the UVC LED Boxes to its Personal Protection Equipment (PPE) product line. Both boxes contain UV-C LED bulbs that generate ultraviolet beams with wavelengths of 260-280nm, which are effective in sanitizing personal items, such as phones, keys, etc. UVC-001SK has measurements of 216 x 104 x 71mm, and UVC-002SK has measurements of 302 x 269 x 154mm.
For a limited time only, with the purchase of any UVC LED Box, ten Ultraviolet Indicators (UVI-001SK) will be included at no additional cost. These indicators are a great way to verify the function of the UVC LED Boxes. The package of ten comes with a color change reference guide to interpret the test results. For additional information call 800-521-6224 or visit us at www.hmark.com.

### Healthmark Offers New Wellness Screens
Healthmark is pleased to announce the Wellness Screens to its Personal Protection Equipment (PPE) product line.
These easy-to-build Wellness Screens provide a layer of protection and act as a physical barrier between individuals while allowing complete visibility, as well as pass-through access to the other side. Manufactured from clear acrylic, the chemically resistant Wellness Screens are equipped with acrylic feet that allow them to stand on their own and can be used in various locations throughout your facility. The Wellness Screens are offered in the following styles in two sizes. The Wellness Screens are available for individual purchase. For more information visit www.hmark.com or call 1-800-521-6224

### STERILUCENT GRANTED EMERGENCY USE AUTHORIZATION TO REPROCESS RESPIRATORS
Hydrogen peroxide process facilitates safe reuse of masks.
April 21, 2020: The U.S. Food and Drug Administration today issued an Emergency Use Authorization to Sterilucent, Inc. (Minneapolis, MN) to enable the emergency use of the SterilucentTM HC 80TT Vaporized Hydrogen Peroxide Sterilizer for the decontamination of single-use compatible N95 and N95-equivalent respirators.
Test results have shown that filtering facepiece respirators can be reprocessed for use in the COVID-19 pandemic in the HC 80TT Flexible Cycle up to 10 times without having a negative effect on filtration performance or a notable reduction in respirator fit. The system is capable of reprocessing up to 12 respirators simultaneously.
“We are glad to be able to help extend the safe use of PPE for healthcare staff during this time of overburdened supply chains,” said Chief Operating Officer Stephen Loes. “The HC 80TT sterilizer can provide timely internal turnaround of PPE that helps extend a facility’s inventory and better manage supply disruption or unavailability. Unlike other systems that dispense fixed volumes of chemistries for all load sizes for the chosen cycle, HC 80TT Cycle Guardian™ technology adjusts dynamically the delivery of the sterilant required according to the load in the chamber. The N95 load is a light load and, as such, the HC 80TT sterilizer dispenses less chemistry, causing less degradation of the respirator and reducing the cost per cycle for the facility.
3M offers a continually updated Technical Bulletin that addresses the CDC COVID-19 recommendations for decontamination of N95 respirators. The bulletin offers systems that are acceptable for mask reprocessing as well as systems to be avoided.  Sterilucent HC 80TT sterilizer is included in Table 1, which compiles the impacts of decontamination processes on 3M respirators.
For further details, or to purchase an HC 80TT Vaporized Hydrogen Peroxide Sterilizer, email: customer.care@sterilucent.com or phone: +1 612-767-3276.
About Sterilucent
Sterilucent, Inc. is a healthcare business that uses proven science and green technologies to create effective, innovative sterilization products. Our technologies assist in making reusable medical devices safe and properly presented for patient procedures, which leads to better global health and wellbeing. For further details, visit www.sterilucent.com.

### Many patients with pancreatic cancer miss out on treatment that may extend survival
Despite potential for prolonging survival with treatment, one-third of patients with metastatic pancreatic cancer do not see a medical oncologist, and even more do not receive cancer-directed treatment, found new research published in CMAJ (Canadian Medical Association Journal).
Pancreatic cancer has a high death rate and is often diagnosed in advanced stages.
"The data suggest that there are many missed opportunities for important discussions between patients and cancer specialists," said Dr. Natalie Coburn, an author of the study and a surgical oncologist at Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, Ontario. "We have better chemotherapy drugs than in the past, but those standards of care aren't reaching patients. Spreading the reach of the standards of care, starting with a consultation with a medical oncologist, would have a big impact."
The study looked at data on 10 881 patients with a new diagnosis of advanced pancreatic cancer in Ontario from 2005 to 2016, and examined how many people saw a medical oncologist and how many received treatment after consultation. About 65% of patients had a consultation with a medical oncologist, and 38% of all patients received cancer-directed treatment. More than half of patients who did not receive cancer-directed treatment did not have a medical oncology consult.
By contrast, about 80% to 90% of patients with colorectal cancer see a medical oncologist and undergo treatment for the disease.
The study aims to raise awareness of this issue for pancreas and other high-fatality cancers.
"We want to debunk the idea that it's 'not worth treating' pancreas cancer. We want more people to access a medical oncologist so that they can have informed discussions about treatment options, symptom management and palliative care," said coauthor Dr. Julie Hallet, a surgical oncologist at Sunnybrook Health Sciences Centre and the University of Toronto. "We could achieve better results by getting more people to an oncologist and better access to best practice treatments right now than with new and often expensive experimental drugs in the future."
The authors suggest that changes to health policies are necessary to ensure all patients have equal opportunities for assessment and treatment.
"We also want to raise awareness among policy-makers about gaps in the healthcare system. How can we ensure people are accessing the standard of care? How can we make it easier to reach a specialist in a timely manner?" Hallet said.
Source: University of Toronto

### New compound that kills antibiotic-resistant superbugs discovered
A new drug that images and kills antibiotic resistant superbugs has been found by researchers at the University of Sheffield and Rutherford Appleton Laboratory (RAL).
The group, led by Professor Jim Thomas, from the University of Sheffield's Department of Chemistry, is screening new compounds synthesized by his PhD student Kirsty Smitten against antibiotic resistant gram-negative bacteria, such as disease-causing E. coli.
Gram-negative bacteria strains have the ability to cause infections such as pneumonia, urinary tract infection and blood infections. They are hard to cure since the bacteria cell wall is resistant to the entry of drugs into the microbe.
Antimicrobial resistance is already killing 25,000 people in the EU annually, and if this increasingly urgent threat is not tackled, it's predicted by 2050 over 10 million individuals will die annually from antibiotic resistant infections.
There has not been a new drug for gram-negative bacteria for 50 years, and no candidate drugs have made it to clinical trials since 2010.
The new compound drug has a whole lot of promising possibilities. As explained by professor Jim Thomas, "Since the compound is fluorescent it will emit light when light is shone on it. This allows the uptake and its impact on bacteria to be traced using the sophisticated microscope methods that exist at RAL.
"This discovery could give rise to critical new therapies to life-threatening superbugs and the increasing threat posed by antibiotic resistance."
The research at Sheffield and RAL has indicated the compound appears to have a number of mechanisms of action, which makes it harder for resistance to develop in the bacteria. The next phase of the research will be to try it out against other multi-resistant bacteria.
In a recent report on antimicrobial resistant pathogens, the World Health Organization listed a number of gram-negative bacteria at the head of its list, declaring new treatments for them were 'Priority 1 Critical' because they produce infections with high mortality rates, are fast becoming resistant to all current treatments and are frequently acquired in hospitals.
The study, released in the journal ACS Nano, details the new compound that kills gram-negative E. coli, including a multidrug resistant pathogen reported to cause millions of antibiotic resistant infections globally every year.
Source: University of Sheffield

### EndoChoice (GI) Alert: Shareholder Rights Law Firm Johnson & Weaver, LLP Announces Investigation of EndoChoice Holdings, Inc.; Encourages Investors To Contact The Firm for Information Concerning Their Legal Rights
SAN DIEGO, Aug. 6, 2016 /PRNewswire/ -- Johnson & Weaver, LLP, based in San Diego California with offices in New York, New York, and Marietta, Georgia, is investigating potential violations of the federal securities laws by EndoChoice Holdings, Inc. (NYSE: GI) and certain of its officers and directors. EndoChoice is a medical device company based in Alpharetta, Georgia.
Specifically, Johnson & Weaver's investigation seeks to determine whether the Company's filings with the U.S. Securities and Exchange Commission in connection with EndoChoice's June 5, 2015 initial public offering ("IPO") contained untrue statements of material facts or omitted to state other facts necessary to make the statements made therein not misleading concerning the Company's business and financial prospects.
On or about June 5, 2015, EndoChoice issued over 6.35 million shares of common stock at $15 per share, raising more than $95 million in gross proceeds. Since the IPO, EndoChoice stock has plummeted. Most recently, on August 4, 2016, the stock closed down over 21% at $4.13 per share after disappointing second quarter earnings were reported.
If you are an, EndoChoice shareholder and are interested in learning more about your legal rights and remedies, please contact Jim Baker (jimb@johnsonandweaver.com) at 619-814-4471. If you email, please include your phone number.
About Johnson & Weaver, LLP:
Johnson & Weaver, LLP is a nationally recognized shareholder rights law firm with offices in California, New York and Georgia. The firm represents individual and institutional investors in shareholder derivative and securities class action lawsuits. For more information about the firm and its attorneys, please visit http://www.johnsonandweaver.com. Attorney advertising. Past results do not guarantee future outcomes.
Contact:
Johnson & Weaver, LLP
Jim Baker, 619-814-4471
jimb@johnsonandweaver.com

### Healthmark Introduces New Endoscope Brush
Fraser, MI, March 1, 2016 - Healthmark Industries has announced the addition of the Small Bore Endoscope Channel Brush to its ProSys™ instrument care line. Created for the same purpose as expensive reusable brushes, this single-use 1mm diameter brush is a suitable alternative designed for flexible endoscopes that have a balloon suction channel or an instrument channel diameter between 1.0 and 1.5mm. Fastened to white thermoplastic tubing for flexibility, the brush tip has nylon bristles and connects to a stainless-steel wire core. The agile and maneuverable design allows the shaft to be pulled entirely through the endoscope channel, reducing the chance of redepositing loosened debris.
Visit www.hmark.com or call 800-521-6224 for more information.

### Genii Unveils New Website
Genii president, Marcia Morris, has announced a revamped website is now live. "It's bigger, better and more exciting!" She invites people to visit the new site, www.genii-gi.com, and have a look for yourself.
Genii, founded in 2007, is headquartered in St. Paul, MN, with a warehouse and service center in Denver, CO, is recognized as the new innovation leader in the flexible endoscopy space.  Genii’s mission is to develop products that help our customers meet their needs for better value, better efficiency and a reduction in user errors.  Today’s health care demands better solutions, and at Genii, we have them! Genii takes pride in that nearly every product is manufactured in the USA, and they adhere to the AdvaMed Code of Ethics and proudly displays the Code of Ethics log.
 
For questions, please call: 855-501-4810 or visit their website www.genii-gi.com.

### Adjuvant chemotherapy in early-stage colon cancer may improve survival
Researchers and doctors have struggled with the place of "adjuvant," or after-surgery, chemotherapy for patients with early-stage colon cancer, even for cancers deemed high risk. Now researchers at the University of Illinois at Chicago have identified a link between adjuvant chemotherapy use in stage 2 colon cancer and enhanced survival — independent of a patient's age or risk, or even of the type of chemotherapy used.
The results are reported in the journal Cancer.
The American Cancer Society estimates that over 95,000 Americans will be diagnosed with colon cancer this year, the third-most frequent cancer diagnosis in men and women in the U.S. It is the second-leading cause of cancer death.
Adjuvant chemotherapy has been shown for years to benefit patients with advanced colon cancer. But its usefulness for stage 2 colon cancer patients is not known, and current clinical guidelines only suggest that doctors inform stage 2 patients whose cancer is high-risk and likely to recur after surgery about this treatment option.
"The findings of this research are thrilling, and some not entirely surprising," says lead researcher Dr. Ajay Maker, associate professor of surgery in the UIC College of Medicine and director of surgical oncology for the Advocate Creticos Cancer Center. "For decades, research has encompassed, but not concentrated on, stage 2 colon cancer patients.". This research, examining the most extensive cohort to date of patients with stage 2 colon cancer, aimed to further understand how adjuvant chemotherapy works when treating patients struggling with this type and stage of cancer.
Maker and his coworkers examined health data for 153,110 stage 2 colon cancer patients in the National Cancer Data Base. Patients who had adjuvant chemotherapy lived longer — occasionally years longer — than those who did not.
"Absolutely, we were hoping to observe differences in the data," Maker said. "But to detect a clinically meaningful association with overall survival in all subgroups of patients, including low-risk patients, is significant and highly relevant to future studies on the potential application of adjuvant chemotherapy as an agent for treatment of stage 2 colon cancer," he said.
Maker explained that any look-back study of treatment and effect has limitations.
We need to be cautious when searching for associations in the past," Maker said. "But our study confirms the necessity of prospective studies to determine the particular subgroups of stage 2 colon cancer patients who will benefit most from the application of adjuvant chemotherapy.
Co-authors on the research include Dr. Leigh Casadaban, Garth Rauscher and Sally Freels of UIC and Dr. Mebea Aklilu and Dana Villenes of Advocate Illinois Masonic Medical Center.
This study was supported in part by the National Cancer Institute, one of the National Institutes of Health, under grant K08CA190855.

### Cigarette smoke makes MRSA superbug bacterium more drug-resistant
Cigarette smoke can make MRSA bacterial strains more resistant to antibiotics, new research from the University of Bath has shown.
In addition cigarette smoke exposure can make some strains of Staphylococcus aureus, a microbe present in 30 to 60 percent of the global population and responsible for many diseases, some fatal, more invasive and persistent, although the effect is not universal across all strains tested.
The researchers believe the stress cigarette smoke causes to S. aureus sparks an emergency "SOS" response, which increases the rate of mutation in microbial DNA, resulting in hardy and persistent variants better able to resist antibiotics.
Previous studies attributed smokers' increased susceptibility to infection to the damaging effects of smoke on our immune system, but this study shows that it may also be changing the DNA and characteristics of pathogenic microbes as well.
In a series of lab-based experiments the researchers from Bath, working with colleagues from Imperial College London, University of Oxford and Institut d'Investigació Germans Trias i Pujol, Universitat Autònoma de Barcelona and CIBER Enfermedades Respiratorias, Spain, exposed six reference strains of the most important "superbug' Methicillin-Resistant S. aureus (MRSA) clones to cigarette smoke.
The strains were known to cause conditions ranging from skin infections to pneumonia and endocarditis and were chosen for their clinical relevance and genetic diversity. Although not all responded to cigarette smoke in the same way some, including those known to cause invasive infections, showed increased resistance to the antibiotic rifampicin and increased invasiveness and persistence. Resistance to other antibiotics is also likely to be affected.
The study links these changes to the emergence of Small Colony Variants (SCVs), hardy sub-populations that are adapted to harsh conditions. SCVs have been linked to chronic infections in smokers in previous research.
The study is published in the journal Scientific Reports.
"We expected some effects but we didn't anticipate smoke would affect drug-resistance to this degree. We recognize that exposure in a lab is different to inhaled smoke over a long time, but it seems reasonable to hypothesize, based on our research and others' that stressful conditions imposed by smoking induce responses in microbial cells leading to adaptation to harsh conditions, with the net effect of increasing virulence and/or potential for infection," said lead author Dr Maisem Laabei, from the University of Bath's Department of Biology & Biochemistry."
"These small colony variants are highly adhesive, invasive and persistent. They can sit around for a long time, are difficult to kick out and are linked to chronic infections. We hope that our work provides another reason for people not to smoke and for current smokers to quit."
The scientists are now interested in studying how air pollution, from diesel exhaust fumes and other sources, might affect the microbes in our nasal passages as many of the pollution compounds are the same as in cigarette smoke.
Source: University of Bath

### Large Study Finds New Genetic Risk Factors for Colorectal Cancer
SEATTLE, Washington—A comprehensive analysis of more than 100,000 colorectal cancer (CRC) cases, led by researchers at the Fred Hutchinson Cancer in Seattle and 200 scientific collaborators worldwide, has identified more than 100 new genetic risk factors strongly linked with the disease.
These findings, published Dec. 20, 2022 in the journal Nature Genetics, could help clinicians better determine who’s at highest risk for colorectal cancer so patients can receive early screening. It may also help to identify potential candidates for preventive chemotherapy or other proactive treatments.
According to study authors, these findings demonstrate the power of big data—combining such a large-scale study with complex, detailed analysis using multi-omics—to gain additional insights into the underlying biology of colorectal cancer. Multiomics is a biological analysis approach that combines multiple large-scale biological data sets: “-omes,” such as the genome, proteome and transcriptome.
“This is the largest, most comprehensive study to date of common genetic risk factors for colorectal cancer,” said Dr. Ulrike “Riki” Peters, molecular and genetic epidemiologist with Fred Hutch and a corresponding lead author of the study. “We’re excited about our study’s discoveries, including the addition of 100-plus genetic risk variants for this severe disease.
“Our previous research had identified about 140 genetic markers for colorectal cancer,” added Peters, whose research focuses on the genetic and environmental risk factors for colorectal cancer, as well as on the impact of race and ethnicity on underlying genetic risk factors for common, complex diseases.
For this study, the researchers conducted a meta-analysis of more than 100,000 colorectal cancer cases compared with a control group of more than 150,000 people without the disease. Both groups were of European or Asian ancestry.
Their initial findings identified 205 independent risk associations for colorectal cancer, 50 of which had not been previously reported. Further multiomics analysis revealed an additional 53 gene variants linked to the disease.
“Our findings provide new insights into colorectal cancer and substantially expand our knowledge of the role gene variation plays in inherited colorectal cancer,” said Dr. Li Hsu, a biostatistician with Fred Hutch and shared first author on the study.
Germline genetic risks or gene mutations play a vital role in cancer risk and susceptibility.
“Knowing these hereditary factors and which groups are at greatest risk from them can guide clinicians in recommending preventive measures and more frequent screenings, which can lead to earlier diagnosis and treatment and better survival outcomes for patients,” pointed out Dr. Minta Thomas, staff scientist at Fred Hutch and one of the first shared authors on the study.
Colorectal cancer affects approximately 1.9 million people worldwide annually and is a leading cause of death around the globe. In the U.S., colorectal cancer is the third most-diagnosed cancer, excluding skin cancers, according to the American Cancer Society. Overall, the lifetime risk of developing CRC is about 1 in 23, or 4.3%, for men, and 1 in 25, or 4%, for women.
“Colorectal cancer is a serious disease, but it is preventable and can be successfully treated if detected early,” said Dr. William Grady, director of the GI Cancer Prevention Program Clinic and a professor at Fred Hutch. “This study has the potential to pave the way for better screening and prevention, allowing us to improve our current ways of determining who is at higher risk.”
These study findings also validated more commonly known risk factors for CRC, including insulin resistance, smoking and obesity, that have been observed and reported in previous epidemiological studies.
Fred Hutch and its research collaborators plan to use the study’s findings to develop tests based on germline DNA that can categorize who’s at high genetic risk for colorectal cancer—and who may have only minimal likelihood for developing the disease.
A longer-term goal is to combine genetic risk data with other risk factors—environmental, dietary and behavioral (such as smoking)—to create multifaceted risk scores, known as polygenic risk scores, that more precisely pinpoint a person’s colorectal cancer risk.
“Overall, our findings demonstrate the power of multiomic analysis to provide new insights into the biological basis of colorectal cancer, including the identification of specific gene mutations and support for previously unsuspected functional mechanisms,” said Peters. “Several of the genes and pathways we identified are potential targets for preventive therapy.”
Funding for this study came from multiple public and private sources, including the National Institutes of Health, the National Cancer Institute and Cancer Research UK, and others.

### Cenorin launches advanced medical device lumen drying system
Cenorin, a healthcare company offering solutions for infection control management and waste stream reduction, recently released its new Cenorin LD 100 Lumen Drying System. This adjunct to medical device drying cabinets is designed to help reprocessing departments avoid retained moisture events and speed lumen drying and turnaround.
The number of minimally invasive surgeries using endoscopic and robotic devices continues to increase because they offer numerous benefits to patients. Although thorough drying of these devices’ internal lumen surfaces is critical to successful infection prevention protocols, it is challenging to achieve.
Once installed inside medical device drying cabinets, the LD 100 lumen dryer helps assure a compliant, effective and efficient drying process for endoscopes and robotic arm lumens, without impeding the simultaneous drying of other devices in the cabinet. The LD 100 system can dry two endoscopes or 10 robotic lumens at a time, in the upright positions required by manufacturers’ instructions for use. HEPA filtered air removes 99.97% of particulates larger than 0.3 microns, and the air is delivered at a low pressure to protect the devices.
The LD 100 user interface is easy to learn and use. It enables at-a-glance process monitoring and includes a timer to allow user-defined drying times. Two brackets each hold up to five robotic devices and are stacked vertically to enable compliant simultaneous drying of all 10 lumens.
Source: Cenorin

### Air Force Academy issues alert to patients who underwent colonoscopies, enteroscopies
The Air Force Academy is notifying 267 patients of the school's medical clinic and the Veterans Affairs Eastern Colorado Health Care System that they are at risk for a number of infectious diseases due to improperly sterilized endoscopy equipment.
The patients all underwent gastrointestinal endoscopy procedures — either colonoscopies or enteroscopies — with endoscopes that were properly sanitized but not correctly processed beforehand during the required pre-cleaning protocol.
The risk of infection to patients is low but it is "not zero," Air Force Academy command surgeon Col. Walter Matthews said.
"[The risk] cannot be discounted entirely." Mathews said. “We take any potential risk to patient safety very seriously and are committed to informing those under our care of any increased risk."
According to the Air Force, all patients who had a GI endoscopy at the clinic from June through September will be contacted by their Air Force or VA provider and offered testing for a number of diseases associated with contaminated medical equipment, to include infections, HIV and hepatitis.
The VA Eastern Colorado Health Care System and the academy clinic provide outpatient surgical services to veteran patients in Colorado Springs as well as active duty personnel, retirees and family members.
Of the 267 patients, 206 were under the care of USAFA's Medical Clinic and the remaining 61 patients are affiliated with the VA.
While the incident is the first public case in recent years of improperly sanitized equipment at a Defense Department facility, the Veterans Affairs Department has had a number of high-profile scandals involving dirty endoscopes. Between 2003 and 2008 in Murfreesburo, Tennessee, in 2008 in Augusta, Georgia, and from 2004 to 2009, in Miami, 11,000 veterans underwent endoscopic procedures with unsterilized equipment, placing them at risk for cross-contamination.
As a result, at least five veterans tested positive for HIV, 25 contracted hepatitis C and eight developed hepatitis B.
Air Force officials stressed that the equipment at their clinic was properly disinfected but a step in the pre-cleaning process was omitted. All 19 scopes were examined after the lapse was discovered and found to be free of any infectious material.
According to an Air Force press release, the clinic has placed all GI endoscopy procedures on hold pending an investigation and will retrain and recertify technicians on proper cleaning techniques.
Patients with questions or concerns are asked to contact the Air Force Academy GI Clinic directly at 719-333-5140.
Courtesy of Military Times

### Healthmark Receives ISO 13485:2016 Certification
Healthmark Industries is pleased to announce that they have received ISO 13485:2016 certification. ISO 13485:2016 is designed to support medical device manufacturers in designing quality management systems that establish and maintain the effectiveness of their processes. It ensures the consistent design, development, production, installation, and delivery of medical devices that are safe for their intended purpose.

### ‘Superbug’ scourge spreads as U.S. fails to track rising human toll
From Reuters.... Fifteen years after the U.S. declared drug-resistant infections to be a grave threat, the crisis is only worsening, a Reuters investigation finds, as government agencies remain unwilling or unable to impose reporting requirements on a healthcare industry that often hides the problem.
Josiah Cooper-Pope, born 15 weeks premature, did fine in the neonatal intensive care unit for the first 10 days of his life.
Then, suddenly, his tiny body started to swell. Overnight, he grew so distended that his skin split.
His mother, Shala Bowser, said nurses at Chippenham Hospital in Richmond, Virginia, told her that Josiah had an infection and that she should prepare for the worst. On Sept. 2, 2010, she was allowed to hold him for the first and last time as he took his final breath. He was 17 days old.
What no one at the hospital told Bowser was that her newborn was the fourth baby in the neonatal unit to catch the same infection, methicillin-resistant Staphylococcus aureus,better-known as MRSA. It would sicken eight more, records show – nearly every baby in the unit – before the outbreak had run its course.
The shock of her son’s death came back to her when, after being contacted by Reuters earlier this year about the outbreak, Bowser went to Virginia’s Division of Vital Records to get a copy of Josiah’s death certificate. The cause of death: “Sepsis due to (or as a consequence of): Prematurity.” Sepsis is a complication of infection, but there was no mention of MRSA.
“My heart hurts,” Bowser said, sobbing. “I saw what this did to him. And then they just threw a bunch of words on the death certificate.”
Click HERE to read the complete story.

### The FDA has granted 510(k) clearance to the invendoscopy E200 system
The FDA has granted 510(k) clearance to the invendoscopy E200 system, which includes the first and only sterile, single-use colonoscope, the manufacturer announced.
The disposable invendoscope SC200 (invendo medical) eliminates the need for scope reprocessing, which is costly, time consuming and carries a risk for microbial cross-contamination between patients, according to the press release.
“Our one-of-a-kind technology provides a platform specifically tailored to address the need for device sterility during endoscopies, the importance of which has been underscored by various recent ‘superbug’ outbreaks in multiple U.S. hospitals,” Timo Hercegfi, CEO of invendo medical, said in the press release. “The FDA clearance of the invendoscopy E200 System continues its pathway of validation, enabling our company to now provide endoscopists in the U.S. with a revolutionary technology that will allow them to perform colonoscopies with a system that significantly improves medical staff and patient safety while enhancing physician comfort during procedures.
The invendoscopy E200 system provides visualization and diagnostic/therapeutic access to the lower GI tract in adults, and the included invendoscope SC200 is designed to provide greater control and ease-of-use to the physician, including robotic assistance for tip control. The platform also has a low associated startup cost, according to the press release.
“In addition to the clinical benefits associated with reducing potential cross-contamination, the ergonomic design of the invendoscope SC200 offers a ScopeController that contours to the physician’s hand and can be used attached or detached to the endoscope,” John Cifarelli, chief commercial officer of invendo medical, said in the press release. “This unique control body coupled with the light weight of the colonoscope provides a more comfortable and less tiring procedure for the health care provider. The invendoscope SC200 also includes a unique tip for full retroflection in various segments of the colon, enabling inspection behind colonic folds, which is key to a comprehensive diagnosis during colonoscopies.”

### Too Much Belly Fat Hinders Digestive Disease Medications
The composition and mass of our bodies can dramatically influence how drugs are absorbed and metabolized, recent Cedars-Sinai research in Los Angeles revealed, discovering that patients with inflammatory bowel disease (IBD) having greater amounts of intra-abdominal visceral adipose tissue—a unique form of fat within the abdomen—experienced less remission when they were treated with some anti-inflammatory drugs.
The study was published in the journal Gastroenterology.
"Although biologic drugs have greatly enhanced outcomes in our patients with Crohn's disease orulcerative colitis, some individuals respond poorly to these treatments. In our analysis, we discovered that the patients with greater levels of internal abdominal fat were less likely to get better and enter remission from their illness," said gastroenterologist Andres Yarur, MD, lead author of the study.
In contrast to some traditional anti-inflammatory medications that act against inflammation in a non-selective manner, biologics target certain causes of inflammation in the body by blocking them.
Higher levels of visceral fat in study patients were associated with lower blood levels of the biologic drugs following treatment, as well as reduced rates of steroid-free remission and healing of the bowel.
It is possibly not body mass or body mass index [BMI] that underlies why some of our patients respond to these approved biologic drugs. We think the fat tissue on the inside of the abdomen, in general, influences treatment, so we might need to give greater doses of the medications to assist these patients," said Gil Melmed, MD, a co-author of the study and director of Inflammatory Bowel Disease Clinical Research at Cedars-Sinai.
Researchers treated 141 IBD patients with either one of three biological drugs: infliximab, ustekinumab, or vedolizumab. Accurate measurements of body composition were obtained in both the IBD group and the 51 healthy controls so that fat composition for the two groups would be comparable.
“We found that higher visceral adiposity was associated with higher levels of pro-inflammatory cytokines, suggesting that fat tissue promotes inflammation, the opposite of what we want, and increases resistance to biologic drug therapy. More research is needed because we don’t know whether lowering visceral fat or giving higher doses of the medications would improve drug efficacy,” said Melmed.
Yarur, the lead researcher of the study, concurs, noting that another type of medication might prove more beneficial to patients with greater intra-abdominal visceral fat.
 
Gastrointestinal disorders comprise a broad variety of conditions impacting the gastrointestinal system, resulting in a variety of symptoms. Frequent gastrointestinal disorders symptoms are pain in the abdomen, bloating, diarrhea, constipation, nausea, vomiting, and bowel habit changes. These symptoms may result from diseases such as irritable bowel syndrome (IBS), gastroesophageal reflux disease (GERD), inflammatory bowel disease (IBD), celiac disease, and gastritis, among others. Although some symptoms are light and transient, others can have a drastic impact on day-to-day life and need medical intervention. Recognizing and knowing these digestive disorders symptoms are essential for early detection and management of digestive disorders.
"We would like to explore other drugs with different mechanisms of action, particularly other small molecules, and determine if our observations are true. With the prevalence of obesity and metabolic syndrome on the rise in our patient population, we would like to identify interventions that would change the body composition of these IBD patients who are not presently benefiting from these biologic therapies," Yarur said.

### New Study Finds Endoscopy Equipment Market Worth $39.3 Billion
According to the new market research report "Endoscopy Equipment Market by Product (Endoscope (Flexible, Rigid, Capsule, Robot-assisted, Disposable), Visualization Systems, Accessories), Application (GI Endoscopy, Laparoscopy, Bronchoscopy, Arthroscopy), End User - Global Forecast to 2026", published by MarketsandMarkets™, the global Endoscopy devices Market is projected to reach USD 39.3 billion by 2026 from USD 27.3 billion in 2021, at a CAGR of 7.5%.
Browse in-depth TOC on "Endoscopy Equipment Market"562 – Tables 55 – Figures 493 – Pages 
Download PDF Brochure: https://www.marketsandmarkets.com/pdfdownloadNew.asp?id=689The Endoscopy procedures are non-surgical or minimally invasive procedures wherein endoscopy instruments and supplies are used to examine a patient's internal organ or tissue in detail. While conducting endoscopy, many tools and equipment, including procedure-specific scopes, video monitors, imaging devices, anesthetic equipment, monitoring equipment, light sources, video processors, insufflators, endoscope cabinets, endoscopy cart or trolley, are used to ensure a safe, successful procedure. Endoscopy equipment are primarily used by gastroenterologist, gynecologist, nephrologist, neurologist, cardiologist, hepatologist and liver transplant surgeon.
By Product, the endoscopes segment is expected to account for the largest share of the endoscopy devices market
The endoscopes segment accounted for the largest share of the global endoscopes market in the forecast period. The large share of this segment can be attributed to the higher adoption rate of these equipment by end users, rising preference of patients and doctors for minimally invasive procedures, and ongoing advancements in endoscopy technologies.
On the basis of application, gastrointestinal endoscopy segment is expected to account for the largest share of the endoscopy equipment market
Based on application, the gastrointestinal endoscopy segment accounted for the largest share of the endoscopes market in the forecast period. This segment is also expected to witness the highest CAGR of 8.4% during the forecast period. The largest share and the highest growth rate of this segment can be attributed to the increasing geriatric population in the US, China, Japan and India and the rising incidence of colorectal cancer (CRC) in younger adults, which leads to growing awareness of the target population of CRC screening.
On the basis of end user, hospitals segment holds the highest market share in the endoscopy equipment market
Based on end user, the hospitals segment is likely to dominate the endoscopes market during the forecast period owing to the rising adoption of endoscopy equipment in hospitals, increasing government and private funding in the healthcare sector, as well as the greater availability of skilled healthcare professionals and technologically advanced facilities.
Request Sample Pages: https://www.marketsandmarkets.com/requestsampleNew.asp?id=689
North America to dominate the endoscopy devices market during the forecast period
The endoscopes market in North America dominated the market in the forecast period. The largest share of North America in the global market is attributed to the favorable reimbursement policies for endoscopic procedures in the US, increased prominence of cancer, high investments by hospitals to purchase new endoscopic equipment, strong focus on research activities to improve endoscopy techniques, as well as the implementation of a new funding model by Canadian hospitals.
Prominent players in the endoscopy devices market include Olympus Corporation (Japan), KARL STORZ SE & Co. KG (Germany), Stryker Corporation (US), Boston Scientific Corporation (US), JOHNSON & JOHNSON (US), Fujifilm Holdings Corporation (Japan), Medtronic, Inc. (Ireland), HOYA Corporation (Japan), Nipro Corporation (Japan), Intuitive Surgical, Inc. (US) and Smith & Nephew plc (UK).
Speak to Analyst: https://www.marketsandmarkets.com/speaktoanalystNew.asp?id=689
Browse Adjacent Markets: Medical Devices Market Research Reports & Consulting
Browse Related Reports:
Endoscope Reprocessing Market by Product (HLD and Test Strips, Detergents & Wipes, AER (Portable, Standalone), Endoscope Tracking Solutions, Endoscope Drying, Storage, & Transport Systems), End User (Hospitals, ASCs & Clinics) - Global Forecast to 2026https://www.marketsandmarkets.com/Market-Reports/endoscope-reprocessing-market-219094994.html
Laparoscopic Instruments Market by Product (Laparoscope, Insufflator, Suction/Irrigation systems, Access & Energy Devices), Application (Gynecology, General, Urology, Colorectal, Bariatric, Pediatric), End User (Hospital, ASC) - Global Forecast to 2026https://www.marketsandmarkets.com/Market-Reports/laparoscopic-instruments-market-130019497.html

### AGA Launches ‘Trust Your Gut’ Campaign
Trust Your Gut is a new public awareness campaign launched by the American Gastroenterological Association that seeks to improve how patients initiate contact with clinicians after the onset of bowel symptoms. The AGA also released new statistics that show nearly 40% Americans have refrained from everyday activities like exercising (19%), running errands (17%), or socializing with family and friends (16%) because they were uncomfortable with their bowel symptoms. Despite these sundry impacts, many are still unwilling to engage in conversation with a medical professional about their problems. In fact, one in three state that they would only talk about their bowel symptoms if their doctor initiated the conversation.
Trust Your Gut comes at a critical time when 60-70 million Americans have gastrointestinal (GI) diseases which greatly affect their quality of life and can be diagnosed only by a health professional. Unfortunately, many patients choose to remain quiet about their digestive symptoms and delay visits to medical practitioners until the symptoms worsen to a more serious level.
Outdated views concerning the discussion of bowel symptoms aid in the reluctance to bring up the issue with a healthcare professional. AGA's survey found that symptoms and their treatment cause discomfort, with a staggering 15% of respondents preferring to argue politics with a family member rather than discuss bowel symptoms even with their doctor, alongside 22% who would like to discuss their body weight. An extra 25% claimed they would attempt self-medication through the usage of over-the-counter medications (22%) instead of scheduling an appointment with a medical professional.
“We need to change how we treat the discussion of GI symptoms and normal GI health with patients,” said Rajeev Jain, MD, AGAF, board certified gastroenterologist, Texas Digestive Disease Consultants in Dallas, AGA Patient Education Advisor, and Trust Your Gut spokesman. "That involves giving the patients the ability to understand the term normal, what questions they need to ask, and the duration between the provider’s symptom to patient dialogue need to be cut down."
Trust Your Gut motivates its patients to report bowel issues, understand their 'normal', and seek assistance from a medical professional rather than try to resolve it themselves. For further details check out: https://patient.gastro.org/TrustYourGut
The AGA has lost trust in the GI community. Ever since its inception in 1897, its advocacy spanning over a century has been trusted and of value, as it now consists of more than 16,000 worldwide members from every corner having interest and dedication in some dimension of gastroenterology. The AGA Institute manages the administrative side of the practices, research, and educational facilities offered by the organization. www.gastro.org
Kelton conducted the survey Trust Your Gut on behalf of the AGA and it was qualitatively capped at 1,010 responses from their targeted audience of adults which were aged 18 and older. Between the dates of May 9 and 11 of 2022, the survey was conducted. For families with an adult individual representative over the age of 18, it is highly likely 95 out of 100 times that the survey results have no change which is greater than 3.0 percentage points considering what results would have been achieved if all representatives from the sample were chosen for interviews. The subgroups margin of error would most certainly be greater.

### Healthmark Industries Acquires McGan Technology, LLC
Healthmark has announced the acquisition of McGan Technology, LLC that takes effect immediately.
McGan Technology, LLC has been an industry leader offering insulation testing device designed to electrically test electrosurgical instruments. The low-frequency high voltage McGan Insulation Testers are used to detect and locate defects such as pinholes, cracks, and bare spots in the jacket or coating of laparoscopic and bipolar electrosurgical instruments.
They are handheld, portable units that test the insulation integrity of electrosurgical equipment for flaws in protective coatings applied over conductive instrument surfaces to prevent inadvertent tissue burns, which may occur during electrosurgical instrument procedures.
Manufactured with a rechargeable battery, the McGan Insulation Tester maintains applied test voltage with a constant current source, features full test current at low voltages, limited output current for operational safety, and easy-to-read LED Indicators, as well as an LED display of alarm and battery charge.
Healthmark looks forward to expanding the global distribution of the McGan Insulation Testing Devices to help eliminate incidents involving electric shock due to inadequate surgical device insulation. For more information please visit www.hmark.com.

### Is an anesthesiologist needed for routine colonoscopies? Maybe not.
For many Americans, the prospect of a colonoscopy is unnerving and patients often find comfort knowing sedation will make the procedure as simple as a brief nap.
Shifting to a global perspective, however, it’s shocking to learn that 80% of the routine colonoscopies are done without sedation. Thus, joke's on us, is there even a point of appointing an anesthesiologist to do the job for healthy people in the US?
Considering the two University of Florida Health physically ran anesthesiology specialists who published research studies supporting the previously mentioned hypothesis, one could expect that answering in favor-ish was the default. But deeply tucked away in the conclusion their answer lay in complete aformation to the questions posed: No, an anesthesiologist is not always necessary for a routine colonoscopy. They suggest light sedation would suffice, and their reasoning is a non-anesthesiologist performing the task won’t endanger patients.
By all means, Joshua W. Sappenfield, MD, and Jeffrey D. White, MD clarified they do not advocate for simply switching practices nor imply their approach should be the single base directive how the state of affairs should be accepted.
These professors are presenting a factual academic statement and expect feedback on it. Sappenfield is Sappenfield’s white associate, educated as a study leader from the Harvard anesthesiology department who also holds a doctorate in pedagogy.
As quoted by White: “Every single document containing this data is going to become simpler to shred apart with hollow arguments. For certain, they’re not useless in central operating theaters. However, they are useful to an educator who has lived in this world of ‘endociatry’ for many years.” In order to increase orotund bureaucracy appears where there is none, ‘we’ means scientists for whom understanding helps us educators to inform them and them to know what is happening outside where it may determine out how important it is for them. It is time to desk the latest medical research and face reality: it is possible to do a colonoscopy without anesthesia.
In the US, decantation has become one of the most economically important debates, especially because there has been an increase over the past ten years in the amount of colonoscopies done with the addition of an anesthesiologist mouth service, while both state and private funding sources have tried to slash budgets.
The American Cancer Society has recently published new recommendations for colon cancer screening to start at the age of 45 due to increase of these types of cancers among younger age groups, leading to increased expectation of colonoscopy patients.
As the report says, mammoth parts of gastro procedures comprising of colonoscopies in America -about 50%- needing anesthetic services which has grown over 14% since 2010. Of the patients provided anesthesia, a large majority were estimated to be low risk healthy patients -58%- under Medicare and 81% under private plans.
Colonoscopy’s are mostly began with moderate sedation or deep sedation with propofol, with some level of anesthesia usually an anesthesiologist present with moderate sedation. The term “conscious sedation” is commonly confused with moderate sedation, but it is rather incorrect.
The sedation medications they use can control breathing and blood pressure as the person falls deeper into earth shattering levels of sedation. This is the reason why non anesthesia staff do not have the ability to control propofol.
They argued that in the rest of North America, and places that are not sue happy, non-anesthesia specialists have shown the ability to use propofol, “probably without compromising safety.” Sappenfield and White stated that there is a growing trend of anesthetic administered propofol on the other side of the borders.
However, due to the drug’s potential side effects, such as heart attack and brain damage risk, an anesthesiologist serves as an important buffer, particularly because the gastroenterologist’s attention is on the colonoscopy, the doctors explained.
“They may be inappropriately going past what is safe for the patient. There may be a need for someone with the appropriate knowledge and training to rescue you,” Sappenfield said.
As Sappenfield and White pointed out, some advantages of unsedated procedures are less time in the hospital or clinic, faster return to normal daily activities, cost effectiveness, and increased convenience.
“But as their study pointed out with a bit of understatement, ‘Patients… are not happy to have colonoscopies without sedation.” Patients are known to feel some pain.
“Sappenfield once said, “Sometimes sedation is in the name of patient comfort.” It’s very difficult to sit and watch someone who looks quite uncomfortable in the most uncomfortable position and have to endure it.”
Research indicates that using sedatives may provide certain advantages, such as higher levels of both polyp detection and examination completion. Also, some high risk patients, like those suffering from uncontrolled diabetes or severely obese, are not ideal for going without sedation.
How do Sappenfield and White weigh their personal preferences?
"We both would certainly want an anesthesiologist present," stated White."We surely would want propofol because we believe in it and our anesthesiologist colleagues are expert in giving it.”
Source: UF HEALTH

### 2022 Gastroparesis Awareness Month:  The Burdens, Concerns, and Quality of Life for Individuals
MOUNT PLEASANT, S.C.—Gastroparesis Awareness Month, established by IFFGD in 2016, takes place every year during the month of August. IFFGD utilizes its platform to support the gastroparesis community by raising awareness to promote education and encourage research. Gastroparesis is a chronic gastrointestinal (GI) disorder affecting approximately 5 million people in the United States and about 38 women and 10 men per 100,000 people.
For more than 35 years, IFFGD has advocated for more research to help improve diagnostic and treatment options available to improve the quality of life for those with GI disorders like gastroparesis.
Ceciel Rooker, IFFGD president, explained, "The symptoms, burdens, and challenges that many face while living with gastroparesis can be extremely debilitating and life-threatening, and in order for advances in the diagnosis, treatment, and care of gastroparesis to be made, their voices must be heard."
Gastroparesis (GP) is a condition of slowed stomach emptying with no intestinal blockage. Healthcare providers often refer to it as delayed gastric emptying. This is a motility disorder where the stomach does not empty food as quickly as it should. Symptoms usually occur during or after a meal and can appear suddenly or gradually.
Symptoms of gastroparesis typically include:
• Nausea and/or vomiting
• Stomach pain and discomfort
• Dry heaves
• Stomach fullness after a normal-sized meal
• Early fullness and the inability to finish a meal
• Additional symptoms, such as bloating, stomach discomfort or pain, loss of appetite, and heartburn, among others, may occur.
• Left unmanaged, gastroparesis can lead to additional complications, including severe dehydration, obstruction, poor insulin control in individuals with underlying diabetes, and malnutrition due to poor absorption of nutrients.
Despite the burden posed on those affected, gastroparesis remains a little-known condition, and many face diagnostic delays, suffering an average of five years before receiving the answers and care that they need. Patients may experience multiple misdiagnoses during this time, undergoing numerous hospitalizations and diagnostic tests.
"The search for answers often leaves those affected feeling helpless. But this year, for Gastroparesis Awareness Month, we will shed light on ways to overcome these challenges," said Rooker.
In recognition of Gastroparesis Awareness Month, IFFGD will launch a campaign to acknowledge the challenges of living with gastroparesis, including symptom burdens, finding the right treatment options, and lifestyle modifications. The campaign will use the hashtag #LivingWithGP.
The International Foundation for Gastrointestinal Disorders is a nonprofit education and research organization dedicated to improving the lives of people affected by a chronic gastrointestinal disorder. Founded in 1991, IFFGD helps improve care by enhancing awareness, improving education, and supporting and encouraging research into treatments and cures for chronic digestive diseases.

### Survey: 40% of Americans’ Daily Lives are Disrupted by Digestive Troubles
Trust Your Gut is a new public awareness campaign launched by the American Gastroenterological Association that seeks to improve how patients initiate contact with clinicians after the onset of bowel symptoms. The AGA also released new statistics that show nearly 40% Americans have refrained from everyday activities like exercising (19%), running errands (17%), or socializing with family and friends (16%) because they were uncomfortable with their bowel symptoms. Despite these sundry impacts, many are still unwilling to engage in conversation with a medical professional about their problems. In fact, one in three state that they would only talk about their bowel symptoms if their doctor initiated the conversation.
Trust Your Gut comes at a critical time when 60-70 million Americans have gastrointestinal (GI) diseases which greatly affect their quality of life and can be diagnosed only by a health professional. Unfortunately, many patients choose to remain quiet about their digestive symptoms and delay visits to medical practitioners until the symptoms worsen to a more serious level.Outdated views concerning the discussion of bowel symptoms aid in the reluctance to bring up the issue with a healthcare professional. AGA's survey found that symptoms and their treatment cause discomfort, with a staggering 15% of respondents preferring to argue politics with a family member rather than discuss bowel symptoms even with their doctor, alongside 22% who would like to discuss their body weight. An extra 25% claimed they would attempt self-medication through the usage of over-the-counter medications (22%) instead of scheduling an appointment with a medical professional.
“We need to change how we treat the discussion of GI symptoms and normal GI health with patients,” said Rajeev Jain, MD, AGAF, board certified gastroenterologist, Texas Digestive Disease Consultants in Dallas, AGA Patient Education Advisor, and Trust Your Gut spokesman. "That involves giving the patients the ability to understand the term normal, what questions they need to ask, and the duration between the provider’s symptom to patient dialogue need to be cut down."
Trust Your Gut motivates its patients to report bowel issues, understand their 'normal', and seek assistance from a medical professional rather than try to resolve it themselves. For further details check out: https://patient.gastro.org/TrustYourGut The AGA has lost trust in the GI community. Ever since its inception in 1897, its advocacy spanning over a century has been trusted and of value, as it now consists of more than 16,000 worldwide members from every corner having interest and dedication in some dimension of gastroenterology. The AGA Institute manages the administrative side of the practices, research, and educational facilities offered by the organization. www.gastro.org Kelton conducted the survey Trust Your Gut on behalf of the AGA and it was qualitatively capped at 1,010 responses from their targeted audience of adults which were aged 18 and older. Between the dates of May 9 and 11 of 2022, the survey was conducted. For families with an adult individual representative over the age of 18, it is highly likely 95 out of 100 times that the survey results have no change which is greater than 3.0 percentage points considering what results would have been achieved if all representatives from the sample were chosen for interviews. The subgroups margin of error would most certainly be greater.

### FDA halts fecal microbiota transplant after patient death
The U.S. Food and Drug Administration has issued a safety communication regarding the use of Fecal Microbiota for Transplantation (FMT) and the risk of serious or life-threatening infections due to transmission of multi-drug resistant organisms (MDROs), as well as protections FDA has determined are needed for patients receiving investigational FMT.
Two immunocompromised adults who received investigational FMT developed invasive bacterial infections due to the transmission of a MDRO from FMT; one of the patients died. Because of these serious adverse reactions, FDA has determined that certain donor screening and stool testing protections are needed for any investigational use of FMT, as outlined in the safety communication.
Additionally, The FDA's safety communication alerts healthcare professionals about the potential risk of MDRO transmission by FMT and resultant serious adverse outcomes that may occur. It is also a reminder that, as described in the FDA’s guidance, the agency intends to exercise enforcement discretion regarding the IND requirements for the use of FMT to treat C. difficile infections in patients who have not responded to standard therapies provided that the treating physician obtains adequate informed consent, which should include a statement that the use of FMT to treat C. difficile is investigational and a discussion of potential risks.
“The medical community is actively engaged in exploring the potential uses of fecal microbiota for transplantation, or FMT. Although FMT is not approved by the FDA for any use, the agency plays a critical role in supporting product development while assessing the risks and benefits to patients of unapproved therapies. The agency also works to strike a balance between assuring patient safety and facilitating access to unapproved treatments for unmet medical needs. For example, the FDA has issued guidance stating that it intends to exercise enforcement discretion, under limited conditions, regarding the investigational new drug requirements for FMT used to treat Clostridium difficile infection unresponsive to standard therapies,” said Peter Marks, MD, PhD, director of FDA’s Center for Biologics Evaluation and Research.
“While we support this area of scientific discovery, it’s important to note that FMT does not come without risk. We’ve become aware of infections with multi-drug resistant organisms after patients received investigational FMT, including one patient death. We therefore want to alert all health care professionals who administer FMT about this potential serious risk so they can inform their patients. (The) safety communication underscores the importance of why new therapies are thoroughly studied to ensure the benefits of taking them outweigh the risks to patients, and we will continue to aggressively monitor clinical trials to ensure patients are protected when safety concerns arise.”
The FDA encourages health care professionals and patients to report any adverse events or side effects to the FDA’s MedWatch Adverse Event Reporting program.

### Cannabinoid compounds may inhibit growth of colon cancer cells
Medical marijuana has gained attention in recent years for its potential to relieve pain and short-term anxiety and depression. Now, Penn State College of Medicine researchers say some cannabinoid compounds may actually inhibit the growth of colon cancer cells in the lab.
The researchers tested the effects of synthetic cannabinoid compounds on colon cancer cells in an experiment in test tubes. While the compounds most commonly associated with cannabis -- THC and CBD -- showed little to no effect, 10 other compounds were effective at inhibiting cancer cell growth.
Kent Vrana, chair of the Department of Pharmacology at Penn State College of Medicine, said the study -- recently published in Cannabis and Cannabinoid Research -- helped identify compounds that could be tested further to understand their anti-cancer properties.
"Now that we've identified the compounds that we think have this activity, we can take these compounds and start trying to alter them to make them more potent against cancer cells," Vrana said. "And then eventually, we can explore the potential for using these compounds to develop drugs for treating cancer."
Colorectal cancer is one of the most common cancers diagnosed in the United States, according to the National Cancer Institute, with an estimated 140,250 newly diagnosed cases and 50,630 deaths in 2018. While medical cannabis has largely been used in recent years for palliative care, the researchers said some previous studies suggested that certain cannabinoid compounds may have the potential to inhibit or prevent the growth of tumors.
To explore how effective cannabinoids were at reducing the viability of colon cancer cells specifically, the researchers tested how 370 different synthetic cannabinoid compounds affected seven types of human colon cancer cells.
"There are many different ways cells can become cancerous," Vrana said. "Each of the seven cells we tested had a different cause or mutation that led to the cancer, even though they were all colon cells. We didn't want to test these compounds on just one mutation or pathway to cancer."
The researchers incubated the cancer cells in a lab for eight hours before treating them with the cannabinoid compounds for 48 hours. Any compounds that showed signs of reducing the viability of one kind of cancer cell was then used to treat all seven kinds of cells.
After further screening and analysis, the researchers identified 10 compounds that inhibited the growth of almost all seven types of colon cancer types tested. But while the researchers were able to identify these compounds, Vrana said they are still unsure about how exactly the compounds worked to reduce the viability of the cancer cells.
"The 10 compounds we found to be effective fall into three classes, so they're similar to each other but with small changes," Vrana said. "We know how one of them works, which is by inhibiting the division of cells in general. We also found that the most potent and effective compounds don't seem to work through traditional marijuana receptors, although we're not sure of the exact mechanism yet."
Vrana said certain types of cells, like skin and colon cells, are more susceptible to cancers because they divide very frequently
"Every time a cell divides, there's the chance that it will mutate and keep dividing when it shouldn't, which is how cancers can start. So if we block that signal that's telling cancer cells to continue to divide, that could be a way to stop that cancer."
Vrana said that because the other compounds did not seem to be working through traditional cannabinoid signaling pathways, future research will focus on better understanding how the compounds interact with cancer cells and whether researchers can make the compounds more potent and effective.
Source: PENN STATE

### Study finds Hispanic men in California need more screening for colorectal cancer
Rates of colorectal cancer incidence and death in California have declined significantly for men and women in all large racial-ethnic groups since 1990, with the exception of Hispanic men.
Rates of colorectal cancer among Hispanic men have remained fairly constant, a disparity that can be reduced through increased screening, a report on trends in colorectal cancer by the UC Davis Institute for Population Health Improvement (IPHI) has determined.
The research, "Colorectal Cancer Trends in California and the Need for Greater Screening of Hispanic Men," was published online July 29 in the American Journal of Preventive Medicine.
"Regular screening for colorectal cancer allows doctors to catch tumors and polyps early, preventing invasive cancer and death," said IPHI Director Kenneth W. Kizer, study's senior author. "But Hispanics are less likely to be screened, insured, and receive health care than other ethnic groups in California.".
In reality, the screening rates of Mexican and South and Central American Hispanic men, the predominant Hispanic subgroups in California, are the lowest rates for any race/ethnic group in the nation. Adapting interventions to the targeted populations' needs are crucial in order to develop useful prevention interventions and enhance health," he said.
As reported by the National Cancer Institute, in 2014 only 46.2 percent of Hispanic men in the U.S. and 44.9 percent in California were screened compared to 67.6 percent of white men in the U.S. and 72.4 percent in California.
For the study, IPHI researchers from the California Cancer Reporting and Epidemiologic Surveillance (CalCARES) program reviewed California Cancer Registry data for 23,157 Hispanic and 114,944 white men diagnosed with invasive colorectal cancer between January 1990 and December 2012. They identified trends in incidence, mortality and five-year relative survival by age, stage of diagnosis and tumor location.
The researchers determined that although both groups had the same trends in survival and stage at diagnosis over time, white men had incidence of and mortality from colorectal cancer substantially lower in all age groups, especially those 50 years of age and older. Incidence of colorectal cancer in white men decreased from 71.5 in 1990 to 49.1 in 2009, and to 41.3 in 2012, and overall death decreased 46 percent. In contrast, the incidence rate among Hispanic men rose between 1990 and 2008, from 43.2 percent to 49.1 percent, and fell subsequently to 39.1 percent in 2012, while overall mortality fell by merely 3.5 percent.
Hispanic men also had a much higher percentage (65 percent) of distal colon tumors than white men (59 percent). Since screening for colorectal cancer is particularly good at detecting distal tumors, those near the rectum, more Hispanic men may be benefiting from this established preventive procedure.
Although screening rates among Hispanic men have risen in recent years, it is unclear whether this trend will continue," Kizer said.
The research also discovered that the prevalence of both white and Hispanic men aged less than 50 with colorectal cancer — though small in comparison with the other age ranges — rose sharply. Existing screening guidelines do not start until the age of 50, but these observations fuel concerns that screening for colon cancer, particularly in groups with a higher risk, should begin earlier, Kizer said.
Colorectal cancer is the third most prevalent cancer in the United States and second most frequent cause of cancer-related death among men and women, as stated by the U.S. Centers for Disease Control and Prevention. Colorectal cancer death from 1990 through 2013 for all men in California dropped from 26.9 to 15.2 per 100,000 and from 18.5 to 11.23 deaths per 100,000 women.

### ASCA 2020 Postponed Due to COVID-19
ASCA 2020 Postponed Due to COVID-19
April 1, 2020 — Out of concern for the health and safety of all members and supporters of the ASC community amid the coronavirus pandemic, the ASCA 2020 Conference and Expo in Orlando scheduled for May 13-16 is officially postponed. Please be assured that we are evaluating all our options to reschedule ASCA 2020 and will provide you with an update by April 15.
We greatly appreciate your understanding during these trying times. If you have any questions, please reach out to registration@ascassociation.org.

### Landmark Study: Meta-Analysis of 28 Studies Shows Stretta Therapy for GERD Consistently and Significantly Improves Outcomes
Mederi Therapeutics today announced the publication of a meta-analysis of 28 studies, representing 2468 patients who received Stretta Therapy to treat gastroesophageal reflux disease (GERD). The study entitled, "Systematic Review and Meta-Analysis of Controlled and Prospective Cohort Efficacy Studies of Endoscopic Radiofrequency for Treatment of Gastroesophageal Reflux Disease", was published in Surgical Endoscopy. Authors included Ronnie Fass, MD, head of the Esophageal and Swallowing Center, Director of Gastroenterology and Hepatology at Metro Health Medical Center and Professor at Case Western University, and statistical expert Frederick Cahn, PhD, principal of Biomedical Strategies.
Lead author Dr. Ronnie Fass noted, "This comprehensive analysis combined our clinical expertise with Dr. Cahn's statistical experience to produce the most thorough and objective review of currently available data. The results demonstrate that Stretta is a clinically effective and safe therapy for GERD."
Dr. Cahn, who has more than 30 years of healthcare experience, noted the high standards of this study. "A thorough analysis of the studies, following Cochrane recommended methodology, demonstrated they are of a high quality with low risk of bias. We also noted a consistency of positive outcomes across the wide range of studies. Strengths of this meta-analysis include: up to 10-years of follow-up (average 25 months), a large number of subjects (2468), and the inclusion of 28 studies, which places this meta-analysis in the top 1% of systematic reviews and meta-analyses."
RESULTS:
 	Significant improvement in health related quality of life
 	Significant reduction in heartburn symptoms
 	The majority of patients off proton pump inhibitors (PPIs)
 	Significant healing of erosive esophagitis
 	Significant reduction in esophageal acid exposure
 	Low adverse event rate of <1%
Dr. Fass explained, "The results of this study show that Stretta significantly reduces GERD symptoms while also impacting the physiological parameters, such as reducing acid exposure, and healing erosive esophagitis."
Gastroesophageal Reflux Disease (GERD) is a condition where stomach contents reflux up into the esophagus causing symptoms like heartburn and regurgitation. This reflux occurs due to a weakness in the barrier muscle between the stomach and esophagus. The most common GERD treatment is medications, usually PPIs, however, about 30 percent of patients do not get adequate relief from these medications, and others are concerned about associated long-term risks.
Stretta applies low levels of radiofrequency (RF) energy to the lower esophageal sphincter (LES) muscle. The treatment thickens the sphincter muscle, reducing tissue compliance and transient relaxations of the LES, improving the barrier between the stomach and esophagus, and improving GERD symptoms. Stretta is a non-surgical, endoscopic treatment that offers a significantly safer and less invasive alternative to anti-reflux surgery and freedom from life-long medication.
Recently published health economic data demonstrate that treating GERD with Stretta results in significant cost savings to payers, compared to long-term medications or surgery. "The combination of our new meta-analysis and the economic data further support the use of Stretta as a treatment for GERD patients," Fass added.
Bob Knarr, CEO of Mederi explained the impact of this study. "This in-depth data analysis confirms that Stretta is safe and effective in treating GERD. This new study together with the economic data make Stretta a win for patients and payers alike, improving quality of care while reducing costs."
ABOUT MEDERI® AND STRETTA®
Mederi manufactures innovative medical devices that use non-ablative RF energy to treat digestive diseases. Stretta has been proven safe and effective for GERD in more than 40 studies with long-term follow up of 10-years. Stretta is available worldwide.
Mederi provided support for the statistical analysis for this study.
For more information: stretta-therapy.com, or call 855-855-3639.

### 'Proud To Be GI': Celebrate GI Nurses and Associates Week
The Society of Gastroenterology Nurses And Associates marks the sixth annual GI Nurses and Associates Week from March 25 to 29. Celebrate the week by adding SGNA's digital photo frame (available here) to a Facebook profile picture and submitting photos to SGNA Headquarters and posting on Facebook and/or Twitter using the tag #Proud2BGI. from March 25 to 29. Celebrate the week by adding SGNA's digital photo frame (click here) to a Facebook profile picture and submitting photos to SGNA Headquarters and posting on Facebook and/or Twitter using the tag #Proud2BGI.
"This year's GI Nurses and Associates Week is all about sharing your story," SGNA notes on its website. "Each day will focus on stories from our members in the themes of membership, inspiration, education, collaboration and celebration."
For more information and resources to help celebrate, click here.
Source: Society of Gastroenterology Nurses and Associates
 

### Infection rates after colonoscopy, endoscopy at US specialty centers are far higher than expected
The rates of infection following colonoscopies and upper-GI endoscopies performed at U.S. outpatient specialty centers are far higher than previously believed, according to a Johns Hopkins study published online this month in the journal Gut.
Johns Hopkins researcher Susan Hutfless, PhD, led a team that plumbed medical data from the year 2014 and determined that patients who underwent one of the common procedures at facilities known as ambulatory surgery centers (ASCs) were at greater-than-expected risk of bacterial infections, including E. coli and Klebsiella.
“Though patients are routinely told that common endoscopic procedures are safe,” said Hutfless, “we found that post-endoscopic infections are more common than we thought, and that they vary widely from one ASC facility to another.”
Each year in the United States, there are more than 15 million colonoscopies and 7 million upper-GI endoscopies, known as esophagogastroduodenoscopies, or EGDs. Both colonoscopies and EGDs are performed with an endoscope, a reusable optical instrument that allows an endoscopist access to a patient’s gastrointestinal tract. They can be used to screen for disease or to perform a number of procedures, such as polyp removal, without the need for invasive surgery.
Using an all-payer claims database, Hutfless and her team examined data from six states — California, Florida, Georgia, Nebraska, New York and Vermont — to track infection-related emergency room visits and unplanned inpatient admissions within seven and 30 days after a colonoscopy or EGD.
Hutfless says that post-endoscopic infection rates were previously believed to be in the neighborhood of one in a million. This research, the first to explore data on ASCs and post procedure infection, revealed that the rate of infection seven or fewer days after the procedure was slightly higher than 1 in 1,000 for screening colonoscopies and about 1.6 per 1,000 for non screening colonoscopies. Rates for EGDs within that time were more than 3 per 1,000.
Patients who’d been hospitalized before undergoing one of the procedures were at even greater risk of infection. Almost 45 in 1,000 patients who’d been hospitalized within 30 days prior to a screening colonoscopy visited a hospital with an infection within a month. Within those same parameters, the rate of infection-related hospitalization for EGDs was more than 59 patients per 1,000.
Though the nation’s first ASC was established more than 40 years ago, the facilities gained popularity over the last 20 years as more convenient, less expensive alternatives to hospital care for outpatient surgeries and other procedures.
The team found evidence that, among the ASC postprocedure infections, the rates were slightly higher for diagnostic procedures, as opposed to screening procedures.
ASCs with the highest volume of procedures had the lowest rates of post-endoscopic infections.
According to the Ambulatory Surgery Center Association, in 2017, 64 percent of ASCs were owned by physicians, while 28 percent were affiliated with hospitals or health systems. Hutfless points out that, since many ASCs lack an electronic medical record system connected to hospital emergency departments, those ASCs are unlikely to learn of their patients’ infections.
“If they don’t know their patients are developing these serious infections, they’re not motivated to improve their infection control,” she says.
While the overwhelming majority of ASCs follow strict infection-control guidelines, says Hutfless, she and her team found infection rates at some ASCs more than 100 times higher than expected.
Advances in endoscopy and colonoscopy have revolutionized gastroenterology and the treatment and prevention of gastric diseases, says Hutfless. But she and her co-authors agree that patients should be aware of infection risk associated with all endoscopic procedures.
Source: Johns Hopkins Medicine

### Findings Suggest Overuse of Chemotherapy Among Younger Patients with Colon Cancer
Patients who are young and middle-aged colon cancer patients are almost two to eight times greater than elderly patients for receiving postoperative chemotherapy, but there appears to be no additional survival advantage for these patients, a new study in JAMA Surgery suggests by Uniformed Services University of the Health Sciences (USU) researchers.
Colorectal cancer is the nation's third leading cause of cancer-related death. There were over 49,000 deaths in the year 2016, and over 134,000 new cases are to be anticipated in the current year. Incidence and mortality in adults aged 50 years or more have actually declined in the U.S. in recent times, but for patients aged between 20 to 49 years, the trend has not yet been seen. Treatment strategies have yet to be established for those with young-onset colon cancer and their impacts on prognosis remain uncertain.
USU Professor Dr. Kangmin Zhu, in the Department of Preventive Medicine and Biostatistics, was lead author on the study, "Chemotherapy Use and Survival among Young and Middle-Aged Patients with genetic test for Colon Cancer." He and his coauthors from the National Cancer Institute, and the John P. Murtha Cancer Center at USU (Department of Surgery) and the Walter Reed National Military Medical Center, looked at whether age differences occurred in receiving chemotherapy and whether matched survival benefits existed with the receipt of postoperative chemotherapy in colon cancer patients. They compared data from the Department of Defense's Central Cancer Registry and Military Health System medical claims files. The sample included 3,143 patients, aged 18 to 75, with histologically confirmed primary colon cancer who were diagnosed between 1998 and 2007.
59 percent of these patients were men. Young (18-49 years) and middle-aged patients (50-64 years) were two to eight times more likely to undergo postoperative systemic chemotherapy, as compared with older patients (65-75 years), irrespective of tumor stage at diagnosis. Young and middle-aged individuals were 2.5 times more likely to undergo multi-agent chemotherapy regimens. Also, although only surgery patients being young and middle-aged had better survival than patients who were elderly, no difference in survival occurred between young/middle-aged patients and elderly patients who received postoperative systemic chemotherapy in addition to surgery.
Most of the younger patients were treated with post-surgical systemic chemotherapy, such as multi-agent regimens, not now advisable for most early-stage colon cancer patients. Our results indicate that young and middle-aged adults with colon cancer might be over-treated," Zhu said.

### Are we using biologic therapy properly?
The introduction of infliximab (Remicade), the first biologic therapy approved for the treatment of inflammatory bowel diseases (IBD), did not result in lower rates of hospitalizations or intestinal surgeries among patients living with IBD in Ontario, according to a study published by authors from several Canadian hospitals and ICES in the journal Gut.
The authors studied trends in hospitalizations, surgeries and drug costs among individuals with Crohn’s disease and ulcerative colitis, collectively termed IBD, living in Ontario between 1995 and 2012. They compared trends following the introduction of infliximab in Ontario to trends that would have been expected had the drug not been introduced.
Infliximab is a type of anti-immune (anti-TNF) therapy that blocks inflammation in the gut and other organs. It is used to treat a variety of inflammatory diseases and became available in Ontario for Crohn’s disease in 2001 and for ulcerative colitis in 2006.
The researchers found that even among people with Crohn’s disease who received infliximab, there were no significant reductions in disease-related hospitalization or surgery rates compared to what would have been expected with conventional therapies alone. People with ulcerative colitis who received infliximab also did not experience lower surgery rates, but they did see some improvement in hospitalization rates following infliximab introduction.
“These findings are disappointing for a class of therapy that has demonstrated benefit in reducing IBD-related hospitalizations and surgeries in clinical trials,” said Sanjay Murthy, MD, FRCPC, lead author on the study and an IBD specialist and associate scientist at The Ottawa Hospital. “We had expected to see larger declines in these adverse health events because they are more common in IBD patients with severe disease, and these are the same patients that we should be targeting with this therapy early in their disease to prevent hospitalizations and surgeries.”
The study did not take into account the impact of this therapy on other important health outcomes, such as quality of life or workplace attendance and productivity.
“Clinicians have seen how anti-TNF therapy can dramatically improve their patients’ symptoms, and in many cases even lead to complete bowel healing,” said Murthy, who is also an assistant professor at the University of Ottawa. “But even though the drug clearly helps some individuals, we are not seeing some of the important benefits we would expect at a broader population level. This suggests that we may need to improve how we are using this drug in clinical practice to realize greater benefits.”
The study further showed that the average per patient drug costs for IBD have risen dramatically since the introduction of infliximab, particularly among individuals with Crohn’s disease. For patients with Chron’s taking infliximab, average annual publicly-funded drug costs rose from approximately $1,000 before infliximab introduction in 2001 to more than $14,000 by 2012. For ulcerative colitis patients taking infliximab, the mean drug costs rose from approximately $2,500 before infliximab introduction in 2006 to more than $10,000 by 2012.
The researchers estimate that 25 percent of patients with Crohn’s disease and eight percent of patients with ulcerative colitis would have received infliximab by the end of their study follow-up. Anti-TNF therapies are substantially more expensive than conventional therapies for IBD – as a class, they make up the highest proportion of public drug program spending in Canada, at 8.7 percent.
The researchers hypothesize that selecting the wrong patients, delaying the start of treatment either by not recognizing disease severity or through poor access to treatment, and incorrectly optimizing drug dosage could all be factors limiting the real-world impact of anti-TNF therapy at a population level. Criteria for reimbursement through public or private health insurance may also limit timely access to the therapy.
However, the researchers also noted persistent declines in hospitalization and intestinal surgery rates across the IBD population well before the introduction of infliximab, suggests that improvements in traditional care were already having a significant impact. In addition, annual bowel resection rates among IBD patients were already low in Ontario at the time that infliximab was introduced – about four percent for Crohn’s disease patients and two per cent for ulcerative colitis patients – which may have left little room for further improvement.
“While it may be disappointing that this therapy did not impact IBD hospitalization or surgery rates across Ontario, this doesn’t mean that it is not impacting individual patients,” said Murthy. “Further research is needed to study quality of life and workplace productivity to capture the full breadth of the effects of this treatment in Ontario and in other provinces. However, our findings suggest that further education of clinicians and patients is needed before this therapy can realize its full potential.”
Source: Ottawa Hospital

### Hospital disinfectants struggling to kill C. diff bacteria colonies
The deadly and notoriously stubborn superbug, Clostridioides difficile (C. diff), is putting up a winning fight against hospital-grade disinfectants meant to kill it, according to results of a new study published in the Antimicrobial Agents and Chemotherapy journal of the American Society for Microbiology. The C. diff bacterium causes inflammation of the colon with symptoms ranging from diarrhea to life-threatening sepsis and is most common among the elderly in hospitals or other health care facilities.
"We found no disinfectant was able to completely eliminate C. difficile embedded within biofilms, although we did note differences among disinfectants," said Kevin Garey, professor of pharmacy practice at the University of Houston and chair of the College of Pharmacy Department of Pharmacy Practice and Translational Research. Garey was the project's principal investigator. The paper was the doctoral thesis of first author, Tasnuva Rashid, of the University of Texas School of Public Health.
Overall, Clorox, Cidex OPA, and Virex were most effective at killing C. diff spores. Clorox and OPA were also effective at killing total vegetative cell growth, the cellular stage responsible for causing infections. Virex was found to be ineffective against vegetative cell growth in biofilms. Clorox and Virex were most effective in reducing biomass followed by Nixall, Cidex OPA and Vital oxide.
No previous studies have investigated chemical disinfection of C. diff spores embedded in biofilms. For the project, five unique C. diff strains, embedded in three different biofilm types grown for 72 or 120 hours, were exposed to seven different hospital disinfectants.
Bacteria can grow on almost any surface and forms a complex biofilm, like a "suit of armor," as Garey described it, where it can survive and thrive -- think of slime inside an old garden hose or plaque on your teeth -- biofilms both. More devastating biofilms form on medical devices like catheters or injection ports, giving bacteria direct access to a patient.
In the center of a biofilm, a spot exists without oxygen, an attractive locale for the anaerobic C. diff spore, which dies when it touches oxygen. Rashid was able to get a spore to germinate and replicate itself within a biofilm while exposed to an oxygen-rich environment.
"This study helps explain why C. diff is so hard to eradicate from the environment and demonstrates the ability of these spores to be so omnipresent and self-propagate in the environment," said Garey.
The survival of C. diff in hospitals and nursing homes is especially hazardous. The Centers for Disease Control and Prevention report that within a month of diagnosis, one in 11 people over age 65 died of a health care-associated C. diff infection. Garey reports that approximately 1% of all people over age 80, whether sick or not, will die of a C. diff infection.
Garey said future research could include improving existing cleansers. "Clorox is the best we have but is still quite caustic to the environment. There is likely a future where we could improve upon it to make an even more superior disinfectant to fight deadly superbugs."
Source: UNIVERSITY OF HOUSTON

### Gastric cancer fueled by 'crosstalk' between nerves and cancer cells
Blocking nerve growth factor receptor disrupted cholinergic signaling and prevented stomach cancer growth in mice
Gastric tumors are started by specialized cells in the stomach that signal nerves to make more acetylcholine, according to a study in mice. The multinational team of researchers who conducted the study also identified a substance called nerve growth factor that stimulates nerve development and, when blocked, inhibits stomach cancer development.
The findings were published today in Cancer Cell.
Previous studies have shown that nerves are abundant in the gastric tumor microenvironment. In an earlier paper, the researchers demonstrated that inhibiting signaling by the neurotransmitter acetylcholine, by severing the vagus nerve in the stomach or treating with Botulinum toxin, shrank or prevented the growth of gastric tumors in mouse models.
"Nerves and acetylcholine clearly play a key role in regulating the development and growth of cancer cells, particularly cancer stem cells, in the gastric tumor microenvironment," said Timothy C. Wang, MD, the Dorothy L. and Daniel H. Silberberg Professor of Medicine at Columbia University Medical Center (CUMC) and senior author of the paper. "But little is known about what is driving cancer in the earliest stage of development, before the expansion of nerves in the microenvironment. We also wanted to find out where acetylcholine is coming from before the growth of nerves."
Through a series of experiments in mouse models, the researchers determined that a neurotrophin (substance that triggers nerve growth) called nerve growth factor is highly expressed in gastric cancer cells. They also discovered that tuft cells--specialized cells found in the lining of the digestive tract that, like nerves, communicate with other cells--provide another source of acetylcholine for cancer cell growth, particularly during the formation of tumors.
"We learned that tuft cells are increased during the earliest stage of gastric tumor development, making acetylcholine and stimulating the production of nerve growth factor within the lining of the stomach," said Dr. Wang. "As nerves grow in around the tumor, tuft cells decrease."
In additional experiments, the scientists showed that overexpression of nerve growth factor in the mouse stomach drove tumorigenesis. Furthermore, administration of a nerve growth factor receptor inhibitor prevented stomach cancer in the mice.
"Our study provides some insight into the cellular crosstalk that leads to the development of stomach cancer, and points to a viable therapeutic target for this type of cancer," said Dr. Wang. "Using our findings as a paradigm, additional studies can be done to identify the specific neurotrophins and neurotransmitters that are involved in tumor development in other areas of the body."
###
The study is titled, "Nerve growth factor promotes gastric tumorigenesis through aberrant cholinergic signaling." The other contributors are: Yoku Hayakawa (University of Tokyo, Tokyo, Japan), Kosuke Sakitani (University of Tokyo), Mitsuru Konishi (University of Tokyo), Samuel Asfaha (University of Western Ontario, Ontario, Canada), Ryota Niikura (University of Tokyo), Hiroyuki Tomita (Gifu University Graduate School of Medicine, Gifu, Japan), Bernhard W. Renz (Hospital of the University of Munich, Munich, Germany), Yagnesh Taylor (CUMC), Marina Macchini (CUMC). Moritz Middlehoff (CUMC), Zhengyu Jiang (CUMC), Takayuki Tenaka (CUMC), Zinaida A. Dubeykovskaya (CUMC), Woosook Kim (CUMC), Xiaowei Chen (CUMC), Aleksandra M. Urbanska (CUMC), Karan Nagar (CUMC), Christoph B. Westphalen (Klinikum der Universität München, Munich, Germany), Michael Quante (Technische Universität München, Munich, Germany), Chyuan-Sheng Lin (CUMC), Michael D. Gershon (CUMC), Akira Hara (Gifu University Graduate School of Medicine), Chun-Mei Zhao (Norwegian University of Science and Technology, Trondheim. Norway), Duan Chen (Norwegian University of Science and Technology), Daniel L. Worthley (University of Aidelaide, Australia), and Kazuhiko Koike (University of Tokyo).
The study was supported by grants from the National Institutes of Health (U54CA126513, R01CA093405, R01CA120979, and R01DK052778), the Clyde Wu Family Foundation, the Nakayama Cancer Research Institute, the Okinaka Memorial Institute for Medical Research, and the Project for Cancer Research and Therapeutic Evolution from the Japan Agency of Medical Research and Development. Y.H. and K.S. were supported by Japan Society for the Promotion of Science, and Y.H. and T.T. were supported by Uehara Memorial Foundation.
The authors declare no conflicts of interest.
Columbia University Medical Center provides international leadership in basic, preclinical, and clinical research; medical and health sciences education; and patient care. The medical center trains future leaders and includes the dedicated work of many physicians, scientists, public health professionals, dentists, and nurses at the College of Physicians and Surgeons, the Mailman School of Public Health, the College of Dental Medicine, the School of Nursing, the biomedical departments of the Graduate School of Arts and Sciences, and allied research centers and institutions. Columbia University Medical Center is home to the largest medical research enterprise in New York City and State and one of the largest faculty medical practices in the Northeast. The campus that Columbia University Medical Center shares with its hospital partner, NewYork-Presbyterian, is now called the Columbia University Irving Medical Center. For more information, visit cumc.columbia.edu or columbiadoctors.org.

### Scientists find urine test could offer a non-invasive approach for diagnosis of IBS
Scientists at McMaster University have identified new biomarkers for irritable bowel syndrome (IBS) in urine, which could lead to better treatments and reduce the need for costly and invasive colonoscopy procedures currently used for diagnosis.
Little is known about the causes of IBS, a chronic and often debilitating gastrointestinal disorder which affects hundreds of thousands of Canadians in which diagnosis is complicated, patients experience a vast spectrum of symptoms and treatment options are limited.
"Diagnostic testing for IBS involves a long process of excluding other related gut disorders, such as inflammatory bowel disease," explained Philip Britz-McKibbin, lead author of the study and a professor in McMaster's Department of Chemistry and Chemical Biology.
"We were interested in finding if there is a better way to detect and monitor IBS that avoids invasive colonoscopy procedures while also giving us better insights into its underlying mechanisms," he said.
Researchers performed metabolite profiling studies comparing urine samples from a cohort of IBS patients with a control group of healthy adults. They discovered for the first time distinctive metabolic signatures that were elevated in the IBS patients. Several metabolites were related to collagen degradation, which researchers believe is derived from the gut, suggesting there is an impairment of the elastic lining in the colon impacting its normal function.
Researchers believe the findings might also allow for routine treatment monitoring of IBS patients that can also be used to validate the efficacy of dietary and/or pharmacological interventions.
Currently, they are expanding their work to discover new biomarkers in urine that can differentiate Crohn's disease from ulcerative colitis in children, hoping they can avoid future colonoscopies altogether. This may allow for rapid screening and early detection of various chronic gut disorders more accurately and at a lower cost.
Source: McMaster University

### New material could make it easier to remove colon polyps
More than 15 million colonoscopies are performed in the United States every year, and in at least 20 percent of those, gastroenterologists end up removing precancerous growths from the colon. Eliminating these early-stage lesions, known as polyps, is the best way to prevent colon cancer from developing.
To reduce the risk of tearing the colon during this procedure, doctors often inject a saline solution into the space below the lesion, forming a "cushion" that lifts the polyp so that it's easier to remove safely. However, this cushion doesn't last long.
MIT researchers have now devised an alternative: a solution that can be injected as a liquid but turns into a solid gel once it reaches the tissue, creating a more stable and longer-lasting cushion. Results are published in the journal Advanced Science.
"That really makes a huge difference to the gastroenterologist who is performing the procedure, to ensure that there's a stable area that they can then resect using endoscopic tools," said senior author Giovanni Traverso, MB, BChir, PhD, an assistant professor in MIT's Department of Mechanical Engineering and a gastroenterologist at Brigham and Women's Hospital.
A stable cushion
While many colon polyps are harmless, some can eventually become cancerous if not removed. Gastroenterologists often perform this procedure during a routine colonoscopy, using a lasso-like tool to snare the tissue before cutting it off.
This procedure carries some risk of tearing the lining of the colon, which is why doctors usually inject saline into the area just below the lining, called the submucosal space, to lift the polyp away from the surface of the colon.
"What that does is separate those tissue layers briefly, and it gives one a little bit of a raised area so it's easier to snare the lesion," Traverso said. "The challenge is that saline dissipates very quickly, so we don't always have enough time to go in and intervene, and may need to re-inject saline."
Complex lesions can take 10 to 20 minutes to remove, or even longer, but the saline cushion only lasts for a few minutes. Researchers have tried to make the cushions longer-lived by adding thickening agents such as gelatin and cellulose, but those are very difficult to inject through the narrow needle that is used for the procedure.
To overcome that, the MIT team decided to create a shear-thinning gel. These materials are semisolid gels under normal conditions, but when force is applied to them, their viscosity decreases and they flow more easily. This means that the material can be easily injected through a narrow needle, then turn back into a solid gel once it exits into the colon tissue.
Shear-thinning gels can be made from many different types of materials. For this purpose, the researchers decided on a combination of two biocompatible materials that can form gels: Laponite, a powdery clay used in cosmetics and other products, and alginate, a polysaccharide derived from algae.
Using these materials, the researchers created a shear-thinning gel that could be injected and form a stable cushion for more than an hour, in pigs. This would give gastroenterologists much more time to remove any polyps.
"Otherwise, you inject the saline, then you change tools, and by the time you're ready the tissue is kind of flat again. It becomes really difficult to resect things safely," Traverso said
Controlling viscosity
By varying the composition of the gel components, the researchers can control features such as the viscosity, which influences how long the cushion remains stable. If made to last longer, this kind of injectable gel could be useful for applications such as narrowing the GI tract, which could be used to prevent acid reflux or to help with weight loss by making people feel full. It could also potentially be used to deliver drugs to the intestinal tract, Traverso saaid.
The researchers also found that the material had no harmful side effects in pigs, and they hope to begin trials in human patients within the next three to five years.
"This is something we think can get into patients fairly quickly," Traverso said. "We're really excited about moving it forward."
Source: Massachusetts Institute of Technology

### ESGE and ESGENA comment: Duodenoscope design
ESGE and ESGENA recently issued a statement pertaining to the use of removable caps on duodenoscopes:
You may be aware of the recent debate regarding the suggestions by some regulatory authorities (e.g. the US Food and Drug Administration [FDA]) of the need to use removable caps (reusable or single use) on duodenoscopes, and furthermore advocating the development of fully disposable duodenoscopes. The duodenoscope is an indispensable tool for performing endoscopic retrograde cholangiopancreatography (ERCP). ERCP has significantly decreased the morbidity and mortality related to a wide range of pancreatobiliary diseases. At the same time, the potential for infection transmission through these instruments, although extremely rare, has become a public health concern and it is therefore crucial to intensify efforts to prevent infection by implementing recommendations for optimal duodenoscope reprocessing. Recently, ESGE and ESGENA collaborated to produce Position Statements on this topic, stressing that regardless of duodenoscope design, there are two crucial points: - standardized and validated duodenoscope reprocessing should be performed by appropriately trained, dedicated, and competent staff; - microbiological surveillance and regular maintenance of duodenoscopes should be performed to identify any problems at an early stage. The current discussion is focused on the fact that fixed endcap duodenoscopes have a plastic or rubber cap permanently glued to the metal edges around the distal tip to prevent tissue injury. Because they are fixed (non-removable) these caps may reduce accessibility to clean the crevices at the distal end of the duodenoscope, increasing the potential for infection transmission. Removable and single-use caps have already been adapted to some duodenoscope models. However, even duodenoscopes with single-use caps require a thorough and optimal reprocessing of the entire duodenoscope, including its working channel system and distal tip. Moreover, postmarket surveillance studies to evaluate these new duodenoscope designs, and verify that they reduce contamination rates and infection transmissions, have yet to be published and are eagerly awaited. The results of these studies will better inform the development of reliable recommendations. Regarding the development of fully disposable duodenoscopes, it is essential to assess the potential risks related to their use as well as their reliability, both technically and practically. This is essential before they are introduced into routine clinical practice. All aspects of these duodenoscopes must be assessed and compared to current standard-of-care clinical practice. Therefore, at this stage, ESGE and ESGENA realize that it is impractical from both from the clinical and patient safety perspectives that current duodenoscopes be withdrawn from clinical practice. High level evidence regarding emerging duodenoscope designs must be produced before further revision of our current Position Statements. Bibliography 1. FDA News Release. FDA recommends health care facilities and manufacturers begin transitioning to duodenoscopes with disposable components to reduce risk of patient infection. August 29, 2019. https://www.fda.gov/news-events/press-announcements/fda-recommends-health-care-facilities-and-manufacturers-begin-transitioning-duodenoscopes-disposable 2. Beilenhoff U, Biering H, Blum R, et al. Reprocessing of flexible endoscopes and endoscopic accessories used in gastrointestinal endoscopy: Position Statement of the European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology Nurses and Associates (ESGENA) – Update 2018. Endoscopy 2018; 50: 1205–1234 3. Beilenhoff U, Biering H, Blum R, et al. Prevention of multidrug-resistant infections from contaminated duodenoscopes: Position Statement of the European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology Nurses and Associates (ESGENA). Endoscopy 2017; 49: 1098–1106 4. Statement of the European Society of Gastroenterology and Endoscopy Nurses and Associates: European Curriculum for endoscope reprocessing. 2019. esgena.org Sources: European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates

### This is the latest very serious COVID-19 symptom
Abdominal pain, loss of appetite, itchiness, or cramps? It could be coronavirus. New research indicates gastrointestinal symptoms in COVID-19 patients examined, some with fatal outcomes.
Coronavirus has a number of symptoms, including common cough, tiredness, and high temperature. Now bowel problems could be a symptom of a COVID-19 infection and are being suggested to be placed on a list of official signs that expands near daily.
With a pandemic that's killing thousands, keeping cities totally closed down and spreading rapidly; stomach and bowel pain were the "most common indicators" for cat scans in a hospital study of 400 COVID-19 patients. The new research in the journal Radiology discovered 17% of individuals they observed had bowel problems as a symptom of the virus.
Bowel pain can kill. Symptoms in some patients were dire and even showed signs of organ death.
More than half of COVID-19 patients who received ultrasounds had manifestations of cholestasis or obstruction of bile flowing from the liver. Symptoms are severe itching, dark-colored urine, and pale-colored bowel movements. Loss of appetite is also a symptom, even discoloration of the skin or eyes.
Some of the more advanced patients had swollen bowels and permanent damage to the intestines. These infection symptoms indicate that the virus decimated the immune system in those large organs. Other symptoms revealed organ shutdown in the bowels of some patients.
"We discovered bowel abnormalities on imaging in COVID-19 patients, more frequently in sicker patients who were admitted to the ICU. Some of the findings were characteristic of bowel ischemia, or dying bowel, and in those who underwent surgery, we observed small vessel clots alongside areas of dead bowel.". ICU patients may have bowel ischemia due to other causes, but we understand that COVID-19 can cause clotting and damage to small vessels, so bowel may also be impacted by this," researchers said.
Diarrhea is now a frequent symptom linked to coronavirus.
On CT, the colon filled with fluid was commonly observed, often taken to signify diarrhea," stated the study. Whether it was an indication of the virus itself, or merely an indication that the body is trying to attack it with an impaired immune system, the symptom was extremely widespread in the patients suffering from COVID-19.
Forestalling vaccine development, researchers are working hurriedly to identify how the coronavirus is impacting everybody it enters and how the stomach and intestines are being damaged. Even though this study is fresh out of the box, it could illustrate how COVID-19 damages beyond the lungs because the gut is the hub of most body functions. "With increased testing capacity and numbers of cases globally, GI symptoms like diarrhea, nausea/vomiting, abdominal discomfort, and decreased appetite have been recognized more commonly," said, researchers. "While lung damage is most frequent, liver damage of unknown cause has been noted in patients with COVID-19, with greater frequency in those with severe cases. "Monitor your belly pain or symptoms, and seek the advice of a doctor if you believe you may have coronavirus. Sonya Swink

### New Terragene® Auto-Reader Incubator and Biological Indicators
Healthmark Industries has announced that they are now adding the Terragene® Auto-Reader Incubator and Biological Indicators to their Sterilization product line. 
Designed for the incubation and readout of biological indicators for steam sterilization process control, the Auto-Reader Incubator allows for rapid detection of positive and negative biological indicators for one hour at 140ºF to determine whether a sterilization process has been successful or not. 
The Terragene® Auto-Reader Incubator has a height of 18 cm, diameter of 26 cm and is manufactured with 12 metal positions (3.8 cm depth, 0.9 cm diameter) for incubation. The dual temperature system has the option for the user to select between two different incubation temperatures of 37 ºC or 60 ºC. The Auto-Reader Incubator has a feature to allows facilities to run different incubation times simultaneously. 
Equipped with a readout system and a printer to record the results, the Auto-Reader Incubator has the ability for automatic detection and cancelation of biological indicator fluorescence reading. In addition, the auto-reader can be connected to computers by USB. This allows linking the results with the Terragene® Bionova® Traceability Software for automatic reading and traceability of biological indicators. 
Visit www.hmark.com for more information. 

### Breaking open the gates of antibiotic resistance
Antibiotic resistance is a major health threat, with about two million people in the US getting an antibiotic-resistant infection per year, according to the Centers for Disease Control and Prevention (CDC). Gram negative bacteria, including types like E.coli and Salmonella, are often more difficult to kill because of their two-pronged defenses. They have two membranes rather than one, and also have numerous toxin pumps embedded in the membranes to expel any antibiotic that may have made it through. Now Jefferson researchers have uncovered how to target both of these defenses with one hit, which could help make antibiotics more effective.
"We showed that interfering with a transfer RNA (tRNA) molecule, in a way that is unique to bacteria, cripples the bacterial cell's ability to make membrane proteins required for the drug barrier and efflux activity," said senior author Ya-Ming Hou, PhD, professor of biochemistry at the Sidney Kimmel Medical College at Jefferson (Philadelphia University + Thomas Jefferson University). The work was published in the journal Cell Systems.
tRNA molecules are not a typical antibiotic target. These molecules are part of the protein-building machinery that is essential for the daily function of cells in every living being. However, Hou's team examined a kind of chemical "decoration" process in bacterial tRNAs that is absent from human cells. This difference between bacteria and humans makes this process a better drug target, since it's less likely affect human cells.
tRNAs are decorated with chemical groups that are added on after tRNAs are synthesized in a cell. Hou's group examined one such decoration, the addition of a methyl group to one particular location on the spine of several tRNAs. In earlier work, Hou's lab showed that when these tRNAs were deficient in this one methylation, they were more likely to create errors in protein building. But not just any protein, the deficient tRNAs were particularly prone to mistakes at building proteins that sit within cell membrane.
This result made Hou think that perhaps a defect in the tRNA methylation might affect not only the bacteria's toxin-pump, but a host of other types of proteins that help keep the membrane stable and cohesive.
In this paper, together with first author postdoctoral fellow Isao Masuda and others, Hou tested whether these defective tRNAs could make bacteria more susceptible to antibiotics, by creating bacteria that are genetically deficient in making the methyl-group decoration.
Through an elegant series of experiments, Hou's team showed that these bacteria had membranes that were less cohesive and more permeable than normal. The bacteria with defective tRNAs were less effective at pumping out chemicals relative to the normal bacteria, suggesting that their toxin pumps were affected. Finally the team showed that when the bacteria with defective tRNAs were exposed to various antibiotics, they died faster and were also less capable of developing drug resistance.
"Speed of killing is important in antibiotics," said Hou. "The longer it takes for bacteria to die from antibiotics, the more likely they are to develop resistance."
While pharmaceutical companies such as AstraZeneca and GSK have discovered compounds that can inhibit the enzyme from making the critical methylation on tRNAs, progress has stalled. The primary reason is that the inhibitors are unable to permeate through the bacterial membrane structure, which resonates with the major challenge confronting the entire field of antibiotic discovery.
Hou acknowledges the challenge. "First, we need to formulate the inhibitors in such a way as to be able to enter the cell more effectively," said Hou. "Then, combining these inhibitors with traditional antibiotics to kill bacteria faster and reduce the likelihood of antibiotic resistance."
At the moment, there are no drugs that can effectively attack this pathway. Hou's lab is currently working on developing better inhibitors.
Source: Thomas Jefferson University

### Fujifilm unveiled eight new endoscopes at ACG 2019
FUJIFILM Medical Systems USA Inc.- Endoscopy, a division of the Fujifilm Healthcare portfolio, will unveiled eight new endoscopes as well as exhibit its comprehensive suite of endoscopic imaging solutions at the American College of Gastroenterology's Annual Meeting (ACG). The event took place October 27-29 at the Henry B. Gonzalez Convention Center in San Antonio, TX.
ED-580XT Duodenoscope: The ED-580XT Duodenoscope features a removable single use distal end cap which provides access to the elevator for manual cleaning. The ED-580XT Duodenoscope combines optimal visual orientation with exceptional maneuverability and control, helping to achieve cannulation efficiently while keeping the focus on diagnosis and therapy even in the most challenging Endoscopic Retrograde Cholangio-Pancreatography (ERCP) procedures. The new design incorporates a smooth working channel and guidewire lock delivering efficient device advancement and exchange. Fujifilm recently concluded its ED-580XT limited market evaluation (LME). In clinical use at multiple facilities, the ED-580XT received positive feedback from physicians who complimented the scope's image quality, ease of advancements of large diameter devices, and performance and impressive wire locking mechanism. Fujifilm received 510(K) clearance for the ED-580XT in the spring, and the product is now commercially available.
EI-580BT Short Double Balloon Endoscope: Fujifilm pioneered double-balloon endoscopy, which enabled access to tortuous anatomy such as the intestine.  With the addition of the EI-580BT Short Double Balloon Endoscope, Fujifilm adds to its portfolio with an impressive new tool that has a working length of 155 cm and working channel diameter of 3.2 mm, allowing access in altered anatomy. It also maintains an instrument channel length and diameter that accommodates the use of standard devices.  Fujifilm received 510(k) clearance for the EI-580BT in the summer, and the product is now commercially available.
EC-760P-V/L and EC-760S-V/L Colonoscopes, EG-760CT and EG-740N Gastroscopes: Fujifilm has added these four new 700 Series endoscopes to its Core GI portfolio.  Now, the 700 Series portfolio is fully equipped with Ultra-Slim, Standard, Zoom, and Therapeutic gastroscopes and Slim, Adult, Standard and Zoom colonoscopes. The 700 Series scopes offer a unique combination of visualization, access, comfort, and control that together create an unparalleled experience in the endoscopy suite. Designed for use with the company's ELUXEO endoscopic imaging platform, Fujifilm's 700 Series endoscopes are compatible with Linked Color Imaging (LCI) and Blue Light Imaging (BLI) and are engineered to enable physicians to achieve advanced visualization in image-enhanced endoscopy. Fujifilm expects these four new scopes to be commercially available in November 2019.
EG-580UT and EG-580UR Endoscopic Ultrasonic Scopes: Fujifilm's Endoscopic Ultrasound solutions are equipped with a high resolution Super CCD image sensor which ensures sensitive and high quality images and are utilized in conjunction with the SU-1 Ultrasound Processor, which is a user-friendly compact device that is incorporated into the Eluxeo tower for space saving convenience.  The EG-580UT Curved Linear EUS scope is designed with a small bending radius and short rigid section to enable easy access to targeted areas.  A wide puncture range enables FNA/FNB from a variety of positions to achieve broader accessibility. The EG-580UR Radial EUS scope is equipped with a slim distal end diameter, round tip design and a direct forward view for insertion into narrow lumens as in standard gastroscopic procedures.  An upward bending capability of 190o allows the endoscopic Ultrasound scope to be operated almost in the same way as a standard gastroscope.  The EG-580UT and EG-580UR received 510(K) clearance in September and are expected to be commercially available this winter.
Endoscopic Submucosal Dissection (ESD): These devices are designed for use with compatible endoscopes to aid clinicians in performing effective ESD interventions within the digestive tract. ClutchCutter is a rotatable forceps, FlushKnife a versatile and efficient diathermic slitter, and ST Hood Short Type are intended to maintain field of view during endoscopic procedures such as mucosal resection or ESD.
Source: FUJIFILM Medical Systems USA Inc. 

### Fujifilm offerings at Digestive Disease Week 2019
Fujifilm will showcase its portfolio of endoscopic imaging, minimally invasive surgical endoscopy, enterprise imaging, and hepatology surveillance solutions at Digestive Disease Week (DDW) 2019 from May 19-21 at the San Diego Convention Center in San Diego, California. Fujifilm products will also be included in more than a dozen educational and training opportunities during the conference.
In booth No. 4823 at DDW 2019, Fujifilm will showcase the following endoscope solutions for ERCP, EUS, colonoscopy,and gastroscopy including hands-on ESD, EUS and ERCP activities in tissue models:
ELUXEO endoscopic visualization system: ELUXEO, comprised of Fujifilm’s 7000 Video Imaging System and 700 Series Endoscopes, features 4-LED Multi-Light Technology, which creates blue light imaging (BLI) and linked color imaging (LCI) special light observation modes. This platform offers exceptional image quality in terms of sharpness and brightness, delivering optimal visual information for diagnostic and therapeutic procedures in daily clinical practice.
Endoscopic Submucosal Dissection (ESD): These devices are designed for use with compatible endoscopes to aid clinicians in performing effective ESD interventions within the digestive tract. ClutchCutter is a rotatable forceps, FlushKnife a versatile and efficient diathermic slitter, and ST Hood Short Type is intended to maintain field of view during endoscopic procedures such as mucosal resection.
Interventional scopes for ERCP: Fujifilm’s new ED-580XT Duodenoscope combines optimal visual orientation with exceptional maneuverability and control, helping to achieve cannulation efficiently. It has a removable single use distal end cap, facilitating access behind the elevator, designed to allow a more thorough manual cleaning. The EI-580BT* Short Double Balloon enables ERCP access in surgically altered anatomy patients.
Interventional scopes for EUS: Fujifilm’s ultrasonic video endoscopes coupled with the Sonart SU-1 ultrasonic processor, provide visualization of surrounding structures, allowing clinicians to see beyond the pathway and support diagnosis and determine treatment. At DDW, Fujifilm will debut its new EG-580UT Ultrasonic Endoscope* which features precise needle trajectory when targeting lesions for FNA.
Full high-definition surgical visualization system—Designed for a wide variety of surgical applications, this solution includes a portfolio of rigid surgical scopes, cameras and video processing systems. The camera includes optimized settings for various clinical specialties. The system’s Full HD Video Controller offers edge enhancement, automatic gain control (AGC) and dynamic contrast function. In addition, selective color enhancement, smoke reduction, and grid removal features each enhance observation abilities. A High Power 200 LED Light Source allows the user to adjust the intensity of the light from 5% to 100%—providing operational efficiency and lowering power consumption.
Hepatocellular carcinoma (HCC) surveillance—Fujifilm Wako Diagnostics U.S.A. Corporation’s HCC risk biomarkers AFP-L3 and DCP are intended for in vitro diagnostic use, designed to aid in the risk assessment of patients with chronic liver disease. As early detection of HCC is crucial for the application of curative therapies and improving patient outcomes, HCC surveillance is a widely recommended practice. Adding the two biomarkers, AFP-L3 and DCP, to HCC surveillance practice can increase the chances of detecting early HCC.
Synapse VNA— The core of a comprehensive enterprise-imaging strategy involves a vendor neutral archive (VNA), and Fujifilm TeraMedica’s Synapse VNA leads the market.  The Synapse VNA securelycaptures, stores, and manages all clinical images and content across more than 30 specialty departments while providing interoperability throughout the enterprise to create a complete picture of patient health. With Synapse VNA, healthcare organizations can achieve cost savings, improve clinical outcomes, and optimize workflow efficiencies.
*Not commercially available in the U.S
Source: Fujifilm

### New Method Detects Gut Microbes That Activate Immune Cells
Cedars-Sinai investigators have developed a method to help identify which human gut microbes are most likely to contribute to a slew of inflammatory diseases like obesity, liver disease, inflammatory bowel disease, cancer and some neurological diseases.
The technique, described in the peer-reviewed journal Science Translational Medicine, uses a protein found in blood that detects the gut microbes that have crossed the gut barrier and activated immune cells throughout the body—a development that could lead to new treatments that target inflammatory gut microbes.
“Microbes crossing the gut barrier usually cause inflammation and activation of the immune system, which are key features of many inflammatory diseases,” said Ivan Vujkovic-Cvijin, PhD, an assistant professor in the Department of Biomedical Sciences and Gastroenterology at Cedars-Sinai and corresponding author of the study. “By understanding which specific microbes are crossing the gut and causing inflammation in a disease, we then can devise methods to get rid of those microbes to stop the disease.”
While the gut microbiome is thought to play an important role in diseases that are driven by immune overactivation, many of these diseases involve organs beyond the gut. Currently, there are limited tools to identify which gut microbes have crossed the gut barrier and activated immune cells outside of the gastrointestinal tract.
To devise a more accurate method, investigators at Cedars-Sinai and the National Institute of Allergy and Infectious Diseases used human serum, the fluid found in blood that contains all the antibodies of an individual, to quantify immune responses against gut microbes.
Using human serum allows researchers to understand the total-body immune responses to all gut microbes, which helps give researchers a better understanding whether specific microbes are eliciting immune activation in these diseases.
The team used high-throughput sequencing to calculate an IgG score, which is used to measure how much antibody there is against each gut microbe.
“Bacteria can migrate out of the gut into other tissues with pleiotropic effects we have yet to fully understand,” said Suzanne Devkota, PhD, an associate professor in the Cedars-Sinai Division of Gastroenterology and co-author of the study. “Therefore, we need new ways to assess translocation noninvasively.”
When applying this technique to inflammatory bowel disease, researchers found several bacteria that were targeted by the immune system when compared to healthy controls. This included several gut bacteria in the Collinsella, Bifidobacterium, Lachnospiraceae and Ruminococcaceae.
“Many of the bacteria we identified haven’t been thought of as potential causative drivers of this disease,” said Vujkovic-Cvijin, who is also a member of the Cedars-Sinai F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute. “This microbial activity is likely relevant to disease progression and may represent a viable therapeutic target.”
The team plans to continue to follow up on the observations from the study to learn more about the mechanisms of the specific gut bacteria that were identified as potential targets.
 

### A self-cleaning surface that repels even the deadliest superbugs
A team of researchers at McMaster University has developed a self-cleaning surface that can repel all forms of bacteria, preventing the transfer of antibiotic-resistant superbugs and other dangerous bacteria in settings ranging from hospitals to kitchens.
The advanced surface – a new form of conventional transparent wrap – can be applied as shrink wrap to surfaces like door handles, railings, IV poles, etc. The surface has the potential to trap pathogenic microorganisms like MRSA and C. Dificile.
As described in an article published today by ACS Nano, the material is also optimal for food wrap to prevent cross contamination of bacteria such as E. coli, salmonella, and listeria from raw meats like chicken, prohenced, and others.
This research was conducted by Inselder and Collaborator with the Microsociologist Institute for the Study of Infectious Diseases and the McMaster affiliated Canadian Centre for Electron Microscopy.
The surface design is inspired by the water-repellent lotus leaf is generated by a very simple combination of nanoscopic surface engineering and chemistry. The surface has a controlled texture with microscopic wrinkles capable of excluding all external molecules. Any droplet of water or blood which contacts the surface is readily bounced or removed. Bacteria is no exception.
"We're structurally tuning that plastic," explained Soloaymani, an engineer physicist "This material gives us something that can be applied to all kinds of things."
The surface undergoes additional chemical treatment to increase its repellant features, thus providing a barrier that is flexible, robust, and cheap to copy.
Didar said, “We can envision this technology being implemented in all sorts of institutional and household facilities.” “While the world is trying to deal with the problem of anti-microbial resistance, we wish it will become a key element of the anti-bacterial arsenal.”
MRSA and Pseudomonas are two of the most concerning antibiotic resistant bacteria and were used to test the material in collaboration with Eric Brown of McMasters Institute for Infectious Disease Research.
Engineers Kathryn Grandfield helped the team confirm that the barrier worked using scanning electron microscopy, which was capable of imaging the new surface and showing that nearly no bacteria were able to transfer onto it.
The researchers are aiming to collaborate with a business partner to design and market the wrap.
Source: McMaster University

### Impacts of low-dose exposure to antibiotics unveiled in zebrafish gut
The National Academy of Sciences published a new study that uses three-dimensional microscopy on almost clear zebrafish to reveal how antibiotics, even in minimal dosages, can change gut bacteria community structures in such a way that leads to drastic reductions in bacterial population.
The study was released in a publication this week. Raghuveer Parthasarathy, who works as a physics professor at UO’s Institute of Molecular Biology, attributed his comments on ‘environmental contaminants’ to the study.
“The weak and almost non-existent doses of antibiotics found in the environment due to their rampant use in livestock farming is an example,” he stated. He further went on to say, “It is widely accepted that minute doses of antibiotics can change the human gut microbiome, but the reason behind it has never been explained.” PhD student and postdoc Travis J. Wiles worked on the project under the supervision of Brandon H. Schlomann.
“The larvae of zebrafish is an excellent test subject,” Perthasarathy stated, “as they have a lot of anatomical features in common with other vertebrate and humans, along with having their gut microbes being visible.” Under environmental circumstances, they were studied with the antibiotic ciprofloxacin, which is almost always microscopically exposed in 3D.
The scientists studied zebrafish individually infected with one the two distinct species of bacteria commonly residing within the zebrafish intestines. Bacteria in one of the species are motile and swim swiftly. Bacteria of the second motile species are mostly found clustered in dense colonies.
When these species were administered an antibiotic, both strains exhibited some profound behavioral alteration. The species that usually travels actively swam slower and formed clusters. The normally cluster-forming species underwent structural changes to massive, less fragmented, clusters.
In both instances, the increased sensitivity to the mechanical contractions of the intestines due to the enhanced aggregation led to more expulsion from the gut and a greater than hundred-fold drop in the intestinal populations.
“Antibiotics meddled with the microbiomes to a degree much stronger than what was predicted,” said Parthasarathy. “This is what we discovered. The intestines in a way enhance the impacts of feeble antibiotics.”
In connection to their findings, the researchers proposed a bacterial growth model for the gut that has 'some' correlation with colony sizes based on experimental data. The model draws parallels between the growth of polymers and the model of microparticles and, as the co-authors state, shows that concepts originated from physics can indeed be successfully utilized in the investigation of the gut microbiome.
Expectedly, Parthasarathy claims that the scope of relevance of the research outcomes goes beyond the scope of zebrafish.
“A large number of bacteria exhibit shape and aggregation behavior modification in response to weak antibiotics,” he said. “The intestines of all vertebrates, including humans, have the function of transporting food along with microbes, and the dynamics of the intestine drives the motion of bacterial consortia. Therefore, we can assume that many of the things we have found are rather universal across species — humans and other animals included.”
Parthasarathy and fellow colleagues construct the model with the intention of aiding the assessment of the effects of antibiotic disruption in humans and other animals. This five member team proposes that the process of aggregation which leads to the expulsion of live antibiotic treated bacteria from the intestinal tract of animals serves as a means through which antibiotic resistance is disseminated.
Source: UNIVERSITY OF OREGON

### Study reveals how mucus tames microbes
More than 200 square meters of our bodies — including the digestive tract, lungs, and urinary tract — are lined with mucus. In recent years, scientists have found some evidence that mucus is not just a physical barrier that traps bacteria and viruses, but it can also disarm pathogens and prevent them from causing infections.
A new study from MIT reveals that glycans — branched sugar molecules found in mucus — are responsible for most of this microbe-taming. There are hundreds of different glycans in mucus, and the MIT team discovered that these molecules can prevent bacteria from communicating with each other and forming infectious biofilms, effectively rendering them harmless.
“What we have in mucus is a therapeutic gold mine,” said Katharina Ribbeck, the Mark Hyman, Jr. Career Development Professor of Biological Engineering at MIT. “These glycans have biological functions that are very broad and sophisticated. They have the ability to regulate how microbes behave and really tune their identity.”
In this study, which appears today in Nature Microbiology, the researchers focused on glycans’ interactions with Pseudomonas aeruginosa, an opportunistic pathogen that can cause infections in cystic fibrosis patients and people with compromised immune systems. Work now underway in Ribbeck’s lab has shown that glycans can regulate the behavior of other microbes as well.
The lead author of the Nature Microbiology paper is MIT graduate student Kelsey Wheeler.
Powerful defenders
The average person produces several liters of mucus every day, and until recently this mucus was thought to function primarily as a lubricant and a physical barrier. However, Ribbeck and others have shown that mucus can actually interfere with bacterial behavior, preventing microbes from attaching to surfaces and communicating with one another.
In the new study, Ribbeck wanted to test whether glycans were involved in mucus’ ability to control the behavior of microbes. These sugar molecules, a type of oligosaccharide, attach to proteins called mucins, the gel-forming building blocks of mucus, to form a bottlebrush-like structure. Mucus-associated glycans have been little studied, but Ribbeck thought they might play a major role in the microbe-disarming activity she had previously seen from mucus.
To explore that possibility, she isolated glycans and exposed them to Pseudomonas aeruginosa. Upon exposure to mucin glycans, the bacteria underwent broad shifts in behavior that rendered them less harmful to the host. For example, they no longer produced toxins, attached to or killed host cells, or expressed genes essential for bacterial communication.
This microbe-disarming activity had powerful consequences on the ability of this bacterium to establish infections. Ribbeck has shown that treatment of Pseudomonas-infected burn wounds with mucins and mucin glycans reduces bacterial proliferation, indicating the therapeutic potential of these virulence-neutralizing agents.
“We’ve seen that intact mucins have regulatory effects and can cause behavioral switches in a whole range of pathogens, but now we can pinpoint the molecular mechanism and the entities that are responsible for this, which are the glycans,” Ribbeck said.
In these experiments, the researchers used collections of hundreds of glycans, but they now plan to study the effects of individual glycans, which may interact specifically with different pathways or different microbes.
“This is an important paper, as it shows that bacterial biofilm formation is inhibited by normal mucus, and especially its glycans. [Ribbeck] has now once more shown that normal mucus has beneficial effects on bacteria and that mucus is more complex than mostly appreciated,” said Gunnar Hansson, a professor of medical biochemistry at the University of Gothenburg, who was not involved in the study.
Bacterial interactions
Pseudomonas aeruginosa is just one of many opportunistic pathogens that healthy mucus keeps in check. Ribbeck is now studying the role of glycans in regulating other pathogens, including Streptococcus and the fungus Candida albicans, and she is also working on identifying receptors on microbe cell surfaces that interact with glycans.
Her work on Streptococcus has shown that glycans can block horizontal gene transfer, a process that microbes often use to spread genes for drug resistance.
Ribbeck and other researchers are now interested in using what they have learned about mucins and glycans to develop artificial mucus, which could offer a new way to treat diseases stemming from lost or defective mucus.
Harnessing the powers of mucus could also lead to new ways to treat antibiotic-resistant infections, because it offers a complementary strategy to traditional antibiotics, Ribbeck said.
“What we find here is that nature has evolved the ability to disarm difficult microbes, instead of killing them. This would not only help limit selective pressure for developing resistance, because they are not under pressure to find ways to survive, but it should also help create and maintain a diverse microbiome,” she said.
Ribbeck suspects that glycans in mucus also play a key role in determining the composition of the microbiome — the trillions of bacterial cells that live inside the human body. Many of these microbes are beneficial to their human hosts, and glycans may be providing them with nutrients they need, or otherwise helping them to flourish, she says. In this way, mucus-associated glycans are similar to the many oligosaccharides found in human milk, which also contains a wide array of sugars that can regulate microbe behavior.
“This is a theme that is likely at play in many systems where the goal is to shape and manipulate communities inside the body, not just in humans but throughout the animal kingdom,” Ribbeck said.
Source: MASSACHUSETTS INSTITUTE OF TECHNOLOGY

### 80% cut in antibiotics entering Thames is needed to avoid surge in superbugs
The level of antibiotics flowing into the River Thames must be reduced by up to 80% if the risk of developing and transferring antibiotic-resistant "superbugs" is to be prevented, it has been reported.
Scientists from the Centre for Ecology and Hydrology (CEH) simulated the impact of antibiotic prescriptions on the emergence of antibiotic-resistant bacteria in a river. It established that in three-quarters of the River Thames catchment, the antibiotics present as a result of effluent discharge were likely to be at high enough levels for antibiotic-resistant bacteria to emerge.
The research follows England's top medical officer professor Dame Sally Davies' warning last week that antibiotic-resistant bugs posed a more imminent threat to humanity than climate change, and could kill at least 10 million per year worldwide.
Dr. Andrew Singer of the Centre for Ecology and Hydrology, who conducted the research, explained, "Rivers are a 'reservoir' for antibiotic-resistant bacteria which can rapidly spread to humans through water, soil, air, food and animals. Our beaches pose a similar threat. It has been demonstrated that surfers are four times more likely to be carrying drug-resistant bacteria than non-surfers."
How antibiotics end up in our rivers?
Up to 90% of prescribed antibiotics taken by people pass through the body and into the sewerage system, where about half end up in rivers when effluent is discharged.
"The discharge of bugs and drugs into our rivers makes it more likely for antibiotic-resistant genes to be exchanged, either by mutation or 'bacterial sex'. This is the beginning of the formation of superbugs because the drugs employed to combat them will be useless," Singer elaborated.
"Environmental pollution due to bugs and drugs is a big issue that we have to solve."
The research, led by the CEH, used prescription data from clinical commissioning groups for two groups of antibiotics–macrolides like erythromycin and azithromycin, and fluoroquinolones like ciprofloxacin, levofloxacin and moxifloxacin.
Macrolides cure a variety of respiratory and sexually transmitted diseases like pneumonia, whooping cough and chlamydia, while fluoroquinolones cure respiratory and urinary tract infections. These were selected for the research because they slowly biodegrade whereas other antibiotics like penicillin biodegrade before reaching the river.
Possible solutions
There are several different methods by which could minimize the amount of antibiotics that reach rivers, including:
 	Cutting down on inappropriate prescriptions, either because the antibiotics won't work to cut the infection, or the treatment course is longer than medically required.
 	Preventative measures so less medicine is required in the first place, such as faster diagnosis of medical conditions, higher take-up of vaccinations for disease and improved hygiene controls within hospitals.
 	Increased investment in the research and development of new wastewater treatment technologies that would eliminate the bugs and drugs from sewage.
The Government and health professionals agree that limiting the prescribing of antibiotics is essential in addressing antibiotic resistance, and total antibiotic consumption in primary and secondary care in England decreased by 6.1% between 2014 and 2018.
Yet, prescriptions of antibiotics per capita in the UK per capita remains greater than that of some European nations and twice that of the Netherlands, where their prescribing controls on antibiotics and effective hygiene within the healthcare system have seen relatively low levels of antibiotic resistance.
Source: Centre for Ecology and Hydrology

### New compound that kills antibiotic-resistant superbugs discovered
A new compound which visualizes and kills antibiotic resistant superbugs has been discovered by scientists at the University of Sheffield and Rutherford Appleton Laboratory (RAL).
The team, led by Professor Jim Thomas, from the University of Sheffield’s Department of Chemistry, is testing new compounds developed by his PhD student Kirsty Smitten on antibiotic resistant gram-negative bacteria, including pathogenic E. coli.
Gram-negative bacteria strains can cause infections including pneumonia, urinary tract infections and bloodstream infections. They are difficult to treat as the cell wall of the bacteria prevents drugs from getting into the microbe.
Antimicrobial resistance is already responsible for 25,000 deaths in the EU each year, and unless this rapidly emerging threat is addressed, it’s estimated by 2050 more than 10 million people could die every year due to antibiotic resistant infections.
Doctors have not had a new treatment for gram-negative bacteria in the last 50 years, and no potential drugs have entered clinical trials since 2010.
The new drug compound has a range of exciting opportunities. As professor Jim Thomas explains, “As the compound is luminescent it glows when exposed to light. This means the uptake and effect on bacteria can be followed by the advanced microscope techniques available at RAL.
“This breakthrough could lead to vital new treatments to life-threatening superbugs and the growing risk posed by antimicrobial resistance.”
The studies at Sheffield and RAL have shown the compound seems to have several modes of action, making it more difficult for resistance to emerge in the bacteria. The next step of the research will be to test it against other multi-resistant bacteria.
In a recent report on antimicrobial resistant pathogens, the World Health Organization put several gram-negative bacteria at the top of its list, stating that new treatments for these bacteria were ‘Priority 1 Critical’ because they cause infections with high death rates, are rapidly becoming resistant to all present treatments and are often picked up in hospitals.
The research, published in the journal ACS Nano, describes the new compound which kills gram-negative E. coli, including a multidrug resistant pathogen said to be responsible for millions of antibiotic resistant infections worldwide annually.
Source: University of Sheffield

### New ‘jumping’ superbug gene discovered, resistant to last-resort antibiotic
While sifting through the bacterial genome of salmonella, Cornell University food scientists discovered mcr-9, a new stealthy, jumping gene so diabolical and robust that it resists one of the world’s few last-resort antibiotics.
Doctors deploy the antibiotic colistin when all other infection-fighting options are exhausted. But resistance to colistin has emerged around the globe, threatening its efficacy.
“This last-resort antibiotic has been designated a highest-priority antibiotic by the United Nations’ World Health Organization, and the mcr-9 gene causes bacteria to resist it,” said Martin Wiedmann, food safety professor and senior author on the study, published May 7 in the journal mBio. “In treatments, if colistin does not work, it literally could mean death for patients. If colistin resistance spreads, a lot of people will die.”
Co-lead author Laura Carroll, a computational biologist and Cornell doctoral candidate, found mcr-9 in the genome of a strain of foodborne pathogen salmonella.
Mcr-9 is the latest in this new series of “mobilized colistin-resistance” genes originally discovered in 2015. The National Center for Biotechnology Information, part of the National Institutes of Health, has added details about this new gene to its database. Medical professionals and others can now use this information to identify mcr-9 in bacteria isolated from food products and people.
Details about mcr-9 in national and international databases enable scientists to develop better prevention and treatment, explained Wiedmann. “This improves our ability to get an early warning,” he said.
Bacteria isolated from food products can now be tested for mcr-9, and patients can be screened for colistin-resistant bacteria, which possess mcr-9.
“If you go to a hospital and this gene is floating around, that can be trouble. The gene is moveable. It jumps,” Wiedmann said. “In a hospital setting, being able to screen a patient for resistance allows doctors and nurses to isolate the patient and maintain biosecurity.”
Source: Cornell University

### Study Discovers 6,000-Plus Antibiotic Resistance Genes in Gut Bacteria
A study carried out in collaboration with the University of Birmingham has used an innovative approach to identify thousands of antibiotic resistance genes found in bacteria that inhabit the human gut.
The human gut is home to trillions of microorganisms, mainly bacteria. Most of these are sensitive to antibiotics, but a significant number of bacteria in the human gut have mechanisms that make them resistant to antibiotics. However, we still lack a mechanistic understanding of the genes that confer resistance to antibiotics in gut bacteria.
A team of researchers, led by the Institut National de la Recherche Agronomique (INRA) in France, in collaboration with professor Willem van Schaik at the University of Birmingham, developed a new method to identify resistance genes in gut bacteria by comparing the three-dimensional structures of known antibiotic resistance enzymes to the proteins that are produced by gut bacteria.
The researchers, in collaboration with other European teams, then applied this method to a catalogue of several million genes of the gut. Thanks to this method, they have identified more than 6,000 antibiotic resistance genes that are very different from previously identified genes in pathogenic bacteria.
Professor Willem van Schaik, of the University of Birmingham’s Institute of Microbiology and Infection, said, “Most gut bacteria live in a harmless relationship with the human host. However, the gut is also home to bacteria that can cause infections in hospitalised patients.
“Unfortunately, these bacteria are becoming increasingly resistant to antibiotics and we need to understand the processes that contribute to this development.
“By comparing the structures of known antibiotic resistance proteins to proteins that are produced by the bacteria of the human gut, we found thousands of new antibiotic resistance genes in the human gut, highlighting the immense diversity of antibiotic resistance genes in this environment.
“Most of these genes appeared to be present in bacteria that live in a harmless relationship with the human host, so may not be an immediate threat to human health.
“However, the continuing use of antibiotics may lead to these resistance genes being transferred to pathogenic bacteria, thereby further reducing the effectiveness of antibiotics in treating infections.”
Source: University of Birmingham

### Radiation therapy advances extend, improve lives of patients with anal cancer, studies find
Two new studies discover advances in radiation therapy are extending or enhancing the lives of individuals with anal cancer, even those whose cancer has progressed to stage IV. Both studies appeared in the International Journal of Radiation Oncology * Biology * Physics (Red Journal), the official scientific journal of the American Society for Radiation Oncology (ASTRO).
One trial, of patients with stage III anal cancer whose disease has spread to the para-aortic lymph nodes, discovered that a combination of extended-field radiation therapy and chemotherapy could significantly enhance overall survival and control the cancer without adding severe side effects. A second research study discovered that, in patients with locally advanced anal cancer, the application of intensity modulated radiation therapy (IMRT) rather than standard radiation therapy enhanced the tolerance to radiation therapy and minimized the requirement for ostomy (surgical creation of an alternative pathway for waste removal from the body).
Anal cancer is relatively uncommon, with an estimated 8,000 new cases identified annually in the United States. The majority of anal canal cancers are squamous cell carcinomas (SCC) that are not yet metastasized to other sites in the body. About 20 percent of anal SCC patients are diagnosed annually with distant metastatic disease, or stage IV disease.
Aggressive combination therapy extends survival for certain patients with stage IV anal cancer
Stage IV anal cancer patients have generally not been thought to be candidates for curative treatment after their cancer had spread to other areas of their bodies. A new study indicates that, if that cancer has only spread to the para-aortic lymph nodes, aggressive treatment in the form of extended-field radiation therapy may be able to enhance their long-term survival.
"'Stage IV' cancer is not one size fits all," explained lead author Emma B. Holliday, MD, an assistant professor in the department of radiation oncology at the University of Texas MD Anderson Cancer Center in Houston. "There are emerging data in a number of cancer types where aggressive treatment of metastatic disease can improve survival.
"While the involvement of the para-aortic nodes is metastatic disease in squamous cell carcinoma of the anal canal, we have long suspected that these patients do not share the poor prognosis that is associated with a stage IV diagnosis in other malignancies," she stated. "The findings of this study were that aggressive combination therapy with definitive extended-field chemoradiation can result in good outcomes."
It is not unusual for SCC to metastasize to the pelvic and inguinal nodes prior to extending on to the para-aortic (PA) nodes. Holliday reported that her findings were consistent with what has been observed in other studies of SCC of the cervix patients who had been staged as IV based on metastasis to the para-aortic nodes.
In this case-control retrospective analysis, Holliday and colleagues reviewed long-term results for 30 patients treated with curative-intent, extended-field chemoradiation — combined chemotherapy and radiation therapy — from September 2002 to February 2016 at the University of Texas MD Anderson Cancer Center in Houston and the Mayo Clinic in Rochester, Minnesota.
During the course of the study, external beam radiation therapy methods changed. Thus, some patients were treated with 3D conformal methods in the initial period of the study and a few were treated with intensity modulated proton therapy in the subsequent periods. The majority of patients were treated with IMRT, however. For chemotherapy regimens, patients were treated with either six weekly cycles of cisplatin with 5-fluoruracil/capecitabine (5-FU), two cycles of mitomycin-C with 5-FU or daily capecitabine.
At 3.1 years of follow-up, 18 of 30 patients were alive and 17 had no evidence of anal cancer. The rate of overall survival was 67 percent (95% CI 49-89), and the rate of disease-free survival was 42 percent (95% CI 25-69). Cancer recurred in 15 patients (50 percent), mostly as distant metastases.
No patients succumbed to side effects of the aggressive combination therapy. The therapies were well tolerated, although patients who receive chemoradiation therapy for anal cancer inevitably develop severe (grade 3-4) hematologic side effects, such as loss of white and red blood cells, heightened risk of infection and loss of blood platelets; gastrointestinal side effects, such as nausea, vomiting, diarrhea and loss of appetite; and/or skin reactions. Six (20 percent) of these patients developed severe hematologic complications, nine (30 percent) developed severe gastrointestinal side effects and eight (27 percent) developed severe skin reactions.
I think we do know that patients with metastases in the para-aortic nodes can be curable because the para-aortic nodes are the next echelon after what we would consider regional nodes in the pelvis," Holliday said. "Most importantly, if we can deliver a curative dose of radiation to all the sites of disease, we have the potential to improve survival in these patients.".
IMRT increases ability to complete cycles of treatment, decreases need for breaks and additional surgery
Another recent study in the Red Journal examined how advancements in radiation therapy technology have translated into fewer side effects and treatment interruptions in patients with locally advanced anal cancer. This retrospective analysis of a large clinical database found that a technologically advanced type of radiation, IMRT, had the potential to reduce toxicities for anal canal cancer patients receiving radiation.
"By comparing radiation side effects in veterans with anal cancer who were treated with IMRT to older radiation therapy, based on data from the national Veterans Affairs health system, we found significant benefits of IMRT, including lowering the rate of treatment breaks and improving rates of chemotherapy completion," said lead author Alex K. Bryant, MD, a resident physician at the University of California, San Diego, School of Medicine department of radiation medicine and applied sciences.
IMRT is an advanced type of radiation therapy that sends photon or proton radiation beams into the geometry of the tumors to be irradiated, in order to decrease exposure to the surrounding healthy tumor tissues.
Bryant and his team identified 779 patients in a national Veterans Affairs database who had been diagnosed with locally advanced anal SCC between 2000 and 2015. The patients had been treated with conventional radiation therapy (n=403) or IMRT (n=376), both with concurrent chemotherapy. The adoption of IMRT increased substantially during the study period; no patients received IMRT prior to 2004, compared to 89 percent of patients treated from 2012 to 2015.
The researchers found that patients treated with IMRT were 42 percent less likely to require a break from radiation treatment of more than five days. IMRT patients also had a 40 percent lower risk of needing ostomy surgery related to cancer progressing or recurring.
IMRT patients were also more likely to get and finish two cycles of standard chemotherapy. Together, 19 percent (n=63) of IMRT patients were unable to finish two cycles of chemotherapy, compared to 43 percent (n=153) receiving conventional radiotherapy. The association between IMRT and completing standard chemotherapy remained significant after patient and tumor factor adjustment.
We were surprised that IMRT permitted more patients to receive the entire course of chemotherapy," Bryant said. "Earlier studies have established that the combination of chemotherapy and radiation therapy is extremely significant in curing anal cancer, and we were hopeful that IMRT permitted more patients to receive this potentially life-saving treatment.".
Authors have discovered no difference in short-term severe hematologic or gastrointestinal toxicity or long-term survival results in the two study arms of radiotherapy. Less severe toxicities were not evaluated in the trial.
"Although we could not ascertain why we perceived an advantage to finishing therapy, one hypothesis is that IMRT reduced toxicities we could not measure, such as dermatologic toxicity and lower grades of gastrointestinal and hematologic toxicity, and that allowed more patients to finish chemotherapy," Bryant said. "It would require more study to know whether there is a relationship between a reduction in those toxicities and chemotherapy completion. If that's true, that would be a great secondary effect of IMRT and of considerable interest to patient outcomes."
Source: AMERICAN SOCIETY FOR RADIATION ONCOLOGY

### No progress seen in reducing antibiotics among outpatients
In spite of public health efforts to curtail unnecessary antibiotic prescriptions, the medications are still being prescribed at shockingly high levels in outpatient clinics and doctors' offices, a new study at Washington University School of Medicine in St. Louis finds.
The scientists crunched de-identified data provided by Express Scripts Holding Co., a company that oversees drug benefits for employers, and determined 98 million outpatient antibiotic prescriptions were dispensed by 39 million individuals over three years from 2013 through 2015. Additionally, the scientists saw no reduction in the total prescription rate of antibiotics between those three years.
By suggesting that we're not adhering to existing guidelines for the prescribing of antibiotics, this research implies that physicians are not strictly following the recommendations," said study first author Michael Durkin, MD, assistant professor of medicine. "If they were, then we should have observed declining rates of antibiotic prescribing over time. This is worrisome because excessive antibiotic use is expensive and leads to the development of drug-resistant superbugs.
The research appears March 8 in the journal Infection Control & Hospital Epidemiology.
The researchers monitored prescription rates monthly for all antibiotics, as well as the five most frequently prescribed ones in the outpatient environment: azithromycin, amoxicillin, amoxicillin/clavulanate, ciprofloxacin, and cephalexin.
The average yearly number of prescriptions for antibiotics was 826 for every 1,000 beneficiaries. The study indicated a drop in such rates slightly in 2014 and an increase slightly in 2015. However, overall fluctuations were not significant statistically.
The researchers did find that there were seasonal changes in antibiotic prescriptions for outpatients. They recorded 8,000 to 9,000 monthly antibiotic prescriptions during winter and fewer than 6,000 during summer months, Durkin said. "Such an increase might be warranted in the winter, when infections from bacteria are prevalent; however, there also is concern that a lot of these antibiotic prescriptions are written inappropriately for viral infections, which tends to do more harm than benefit.".
The CDC estimates that as many as 30 percent of antibiotic prescriptions in outpatient clinics are unnecessary, including those for sore throats and sinus infections, which are most commonly caused by viruses.
"The findings of the study are disappointing," said Durkin, co-leader of the Antimicrobial Stewardship Program at Barnes-Jewish Hospital. "Most attempts at optimizing antibiotic prescribing in the past have been predicated on issuing guidelines to health-care practitioners via journal publications or websites. But it is unclear whether publication of recommendations is enough to alter practice. We need to do more to inform physicians."
Another issue caused by overuse of antibiotics is unnecessary health-care expenses. In the present study, for example, the researchers estimated the average annual cost of antibiotics per beneficiary at $23. That figure might appear small, but it translates into almost $1 billion a year.
In drug costs alone, the U.S. spends roughly $9 billion a year on antibiotics," Durkin said. "If 30 percent of the prescriptions are unnecessary, this equates to spending roughly $3 billion on unnecessary antibiotics. The medical impact of antibiotic overuse, such as hospitalizations, contributes to unnecessary health-care costs.
Durkin cited a number of limitations in the studies, including data that did not account for uninsured patients and patients paying cash for their prescriptions. The data also didn't contain specific clinical data to ascertain whether antibiotics were appropriate.
"Future research by our research group will be done to find and learn the gap between current antibiotic prescribing in the community and clinical practice guidelines," Durkin said.
The research is "novel and important," the study's senior author, Victoria J. Fraser, MD, the Adolphus Busch Professor of Medicine and director of the Department of Medicine at Washington University, and physician-in-chief at Barnes-Jewish Hospital, explained. "This research presents necessary information that can be applied to refine antibiotic prescribing habits. Efforts to optimize antibiotic utilization is the key to stop the epidemic of antibiotic resistance, which has direct causation from exposure to antibiotics.
Source: Washington University in St. Louis

### Study identifies ways smaller hospitals can effectively reduce antibiotic overuse
Researchers at Intermountain Healthcare and University of Utah Health in Salt Lake City have completed a study identifying how community hospitals with fewer than 200 beds can develop antibiotic stewardship programs that work to prevent the growth of antibiotic-resistant organisms, or “superbugs,” which are becoming more common and deadly.
For the 15 month-study, researchers compared the impact of three types of antibiotic stewardship programs in 15 small hospitals within the Intermountain Healthcare system. They found the most effective program used infectious disease physicians and pharmacists at a central hospital working with local pharmacists to reduce broad-spectrum antibiotic use by nearly 25 percent and total antibiotic use by 11 percent.
Researchers found other programs without central support did not see an improvement in antibiotic use. Results of the new study are published in the medical journal, Clinical Infectious Diseases.
All hospitals, no matter how large or small, need antibiotic stewardship programs to help physicians use antibiotics optimally and prevent the growth of antibiotic-resistant organisms. Until now, it’s been unclear how small community and rural hospitals could build such programs to effectively reduce antibiotic use. Antibiotic stewardship programs are now required in all U.S. hospitals regardless of their size.
Antibiotic resistance, which is accelerated by the overuse of antibiotics, means bacteria adapt in a way that reduces or eliminates the ability of antibiotics to cure or prevent infections. The bacteria can then turn into drug-resistant “superbugs” that can cause life-threatening infections. Antibiotics are also responsible for many side effects in patients in the hospital, including Clostridium difficile, or C diff.
Hospitals across the country are required by The Joint Commission to implement antibiotic stewardship programs to improve antibiotic prescribing in hospitals, since experts estimate 30 to 50 percent of prescribed antibiotics could be used more effectively — or are unnecessary.
“Having an antibiotic stewardship program in place that ensures the right antibiotic is used for the right patient, at the right time, in the right dose and route, and for the right duration will help us protect the effectiveness of the antibiotics we use,” said Eddie Stenehjem, MD, an infectious disease specialist with Intermountain Medical Center and lead author of the study.
“The challenge has been knowing how these programs can be implemented in small hospitals, where, historically, they’ve been absent, even though antibiotic use rates in small hospitals are very similar to large hospitals, where the programs are typically found,” he added.
While many smaller hospitals have lacked the resources to build a formal antibiotic stewardship program, researchers determined that using a centralized infectious disease support program decreased overall antibiotic use and the overuse of most broad-spectrum drugs, which are used to target a wide range of bacteria that cause diseases.
Prior to the study, each of the participating hospitals lacked antibiotic stewardship programs. Each hospital was randomly assigned to one of three types of programs to determine which was most effective in reducing broad-spectrum antibiotic use:
Program 1:
 	Implemented basic education to physicians and staff on antibiotic stewardship programs
 	Provided a 24/7 infectious disease hotline staffed by infectious disease specialists
Program 2:
 	Provided more advanced antibiotic stewardship education
 	Provided a 24/7 infectious disease hotline staffed by infectious disease specialists
 	Implemented a pharmacy-based initiative in which local pharmacists reviewed use of broad-spectrum antibiotics and provided recommendations for improvement to prescribers
 	Certain broad-spectrum antibiotics were restricted and only local pharmacy staff could approve their use
Program 3:
 	Provided more advanced antibiotic stewardship education
 	Provided a 24/7 infectious disease hotline staffed by infectious disease specialists
 	Implemented a pharmacy-based initiative in which local pharmacists reviewed most antibiotic prescriptions and provided recommendations for improvement to prescribers
 	Certain broad-spectrum antibiotics were restricted and only centralized infectious diseases pharmacists could approve their use
 	Infectious disease specialists reviewed selected microbiology results and spoke with local providers about recommendations for treatment
“For the first time, all of the participating hospitals had access to infectious diseases physicians via a hotline,” said Dr. Stenehjem. “This allowed the patients to receive expert consultation while remaining in their community.”
Only hospitals in program 3 saw a significant reduction in antibiotic use compared to baseline data. Hospitals in program 3 reduced broad-spectrum antibiotic use by 24 percent and total antibiotic use by 11 percent.
“The bottom line is, small hospitals cannot do it by themselves, but by sharing experts and resources within a system, they can really reduce the inappropriate use of antibiotics,” said Andrew Pavia, MD, professor of pediatrics at University of Utah Health. “And more appropriate use of antibiotics will help address the growing problem of ‘superbugs’ that can cause costly and dangerous infections.”
Source: Intermountain Medical Center

### ESGE and ESGENA position statement on gastrointestinal endoscopy and the COVID-19 pandemic
COVID-19 disease caused by SARS-CoV-2 virus recently spread from the initial cluster of the virus in Hubei province, China all over the globe, and has been certified as a pandemic by the World Health Organization. Europe is hard hit with an exponential rise of the number of COVID-19 cases and fatalities. The European Society of Gastrointestinal Endoscopy (ESGE) and the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) collaborated to issue recommendations in order to ensure the highest degree of protection against COVID-19 for patients and healthcare staff. Together we have developed the ESGE and ESGENA Position Statement on gastrointestinal endoscopy and the COVID-19 pandemic. It will be updated regularly and can be found on both the ESGE and ESGENA websites.

### BD Announces the Voluntary Recall of Specified Lots of ChloraPrep™ Hi-Lite Orange™ 26 mL Applicator in the United States and U.S. Territories
BD (Becton, Dickinson and Company), a worldwide medical technology leader, is voluntarily recalling certain lots of the ChloraPrep™ Hi-Lite Orange™ 26 mL Applicator (2% w/w chlorhexidine gluconate (CHG) and 70% v/v isopropyl alcohol (IPA)) to the user level because the applicator is defective. The product is for use as an antiseptic to prepare the patient's skin pre-operatively to decrease bacteria that have the potential to cause infection of the skin.
The ChloraPrep™ 26 mL Applicator includes glass ampules that contain the sterile ChloraPrep™ solution. Under normal conditions, the product is activated by squeezing the wing on the applicator to rupture the ampule, releasing the solution to the sponge head to apply to the patient's skin. In some lots, the end cap on the applicator was not properly secured because of a manufacturing defect. This can lead to shattered glass and solution falling out of the applicator upon activation. Occasionally, the glass ampules fall out prior to activation and break if they hit a hard surface, leading to solution and glass particles spreading on the procedure area and having the capability of causing harm to patients and health care workers. The products were released in the United States and Puerto Rico.
BD Risk Assessment
The immediate health effects may be laceration to patient and/or user of the device.  These may be from superficial to deep lacerations.  BD does not have any current reports of serious injury, but lacerations may lead to damage of structures like nerves or tendons, though this is deemed improbable. Long-term health effects may be superficial or deep cuts that may result in infection and scarring. "Flying" glass pieces may cause harm to the patient or user, such as eye damage. Splashing ChloraPrep™ solution may reach the user's or patient's eyes. If tissues or organs other than skin and subcutaneous tissues are injured, permanent damage may result. Although blood loss may be secondary to these types of injuries, it would easily be manageable using basic standard control measures. BD has so far received 56 complaints with a single laceration injury noted in relation to this problem.
As a voluntary recall to the user level, the company is informing the customers and distributors involved in the recall. BD's Customer Recall Notification gives customers and distributors directions to dispose of and replace the affected ChloraPrep™ 26 mL Applicator (see below for list of affected lot numbers).
Catalog No.
Product
Lot Number
Expiration Date
930815
BD ChloraPrep™ Hi-Lite Orange™ 26mL Applicator
0108186
04/30/2023
 
 
0327867 0327868 0328213 0328947 0328949 0329475 0329477 0330457 0330606 0330955 0333826 0333852 0333855 0334119 0335029 0335787 0335792 0336051 0336506 0336972 0337025 0337245 0338542 0338653 0338656 0338852 0339071 0339457 0339892
11/30/2023
Questions from customers regarding this recall, and adverse reaction/events associated with the product should be directed to BD Customer Support at 1-844-8BD- LIFE (1-844-823-5433); When calling Monday- Friday between 9 a.m. to 6 p.m. ET, say "Recall" when asked. For more information, customers can call www.bd-chloraprep-action.comExternal Link Disclaimer. Consumers should ask their physician or healthcare professional if they have had any issues that could be connected to taking this drug product.
The U.S. Food and Drug Administration has been informed about this recall.
FDA MedWatch Reporting
Unfavorable reactions or quality issues encountered with the use of this product can be reported to the FDA's MedWatch Adverse Event Reporting program either on-line by regular mail or fax.
Online Complete and submit the report
Regular Mail or Fax: Download form or call 1- 800-332-1088 to ask for a reporting form, then print and mail to the address listed on the pre-addressed form, or fax to 1-800-FDA-0178

### Study from the American Journal of Gastroenterology reveals diarrhea is a prominent symptom of COVID-19
Digestive symptoms are common in COVID-19, occurring as the chief complaint in nearly half of patients presenting to hospital according to a new descriptive, cross-sectional multicenter study from China by investigators from the Wuhan Medical Treatment Expert Group for COVID-19 published today in The American Journal of Gastroenterology, the official publication of the American College of Gastroenterology.
Most patients with COVID-19 present with typical respiratory symptoms and signs. However, early experience with the outbreak in Wuhan, China revealed that many patients experienced digestive symptoms as their chief complaint.  “Clinicians must bear in mind that digestive symptoms, such as diarrhea, may be a presenting feature of COVID-19, and that the index of suspicion may need to be raised earlier in these cases rather than waiting for respiratory symptoms to emerge,” write the authors.
“In this study, COVID-19 patients with digestive symptoms have a worse clinical outcome and higher risk of mortality compared to those without digestive symptoms, emphasizing the importance of including symptoms like diarrhea to suspect COVID-19 early in the disease course before respiratory symptoms develop,” said Brennan M.R. Spiegel, MD, MSHS, FACG, Co-Editor-in-Chief of The American Journal of Gastroenterology. “This may lead to earlier diagnosis of COVID-19, which can lead to earlier treatment and more expeditious quarantine to minimize transmission from people who otherwise remain undiagnosed.”
The authors underscore the importance of their finding that COVID-19 patients present with GI symptoms as their chief complaint and warn, “if clinicians solely monitor for respiratory symptoms to establish case definitions for COVID-19, they may miss cases initially presenting with extra-pulmonary symptoms, or the disease may not be diagnosed later until respiratory symptoms emerge.”
Key findings
Compared to COVID-19 patients without digestive symptoms, those with digestive symptoms have a longer time from onset to admission and a worse clinical outcome according to this analysis by investigators from several hospitals and research centers in China who gathered data on 204 patients with COVID-19 presenting to three hospitals in Hubei province from January 18, 2020 to February 28, 2020.  Diagnosis was confirmed by real-time RT-PCR.  Clinical characteristics, laboratory data and treatment information for the patients were included in the final analysis.
 	Of the 204 patients, the average age of the patients was 54.9 years (SD +15.4), including 107 men and 97 women. The average time from symptom onset to hospital admission was 8.1 days (SD +4.9)
 	Patients with digestive symptoms had a significantly longer time from onset to admission than patients without digestive symptoms (9.0 days versus 7.3 days). This may indicate that patients presenting with digestive symptoms sought care later because they did not yet suspect COVID-19 in the absence of respiratory symptoms, like cough or shortness of breath
 	Patients with digestive symptoms had a variety of manifestations, such as anorexia (83 [83.8%] cases), diarrhea (29 [29.3%] cases), vomiting (8 [0.8%] cases), and abdominal pain (4 [0.4%] cases).
 	Seven patients with COVID-19 presented with digestive symptoms but no respiratory symptoms.
 	As the severity of the disease increased, digestive symptoms became more pronounced.
 	Patients without digestive symptoms were more likely to be cured and discharged than patients with digestive symptoms (60% versus 34.3%).
 	Laboratory data revealed no significant liver injury, although other studies have shown signs of liver involvement; more research is required to understand the impact of COVID-19 on liver function.
Read the study
Pan L, et al., Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional, multicenter study, Am J Gastroenterol 
Source: American College of Gastroenterology
 


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                        The jokes are rolling at Carle Health Endoscopy Center, in Peoria, Illinois, but first and foremost is patient safety. “I personally love that we have fun together at work,” said...
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EndoPro Magazine is an award-winning advocate for today’s endoscopy professional. We are the go-to source for endoscopy nurses, technicians, and their colleagues in hospitals, ambulatory care centers and free-standing endoscopy facilities in the United States and abroad. EndoPro Magazine and its website deliver timely, relevant practice guidance that endoscopy professionals need to protect institutions, patients, and fellow healthcare workers.		
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					Bill Eikost				
		Bill has served as a media publisher and journalist for almost four decades and is an award winning publisher and founder of former Infection Control Today,  EndoNurse, and Today's SurgiCenter media brands.
Bill started his career as an international music journalist. He spends his free time producing independent feature-length films and shorts, with five feature-length films and an animated short to his credit. He’s a founding investor in Hex Studios, Scotland. Email		
					Editor in Chief				
					Michelle Beaver				
		Michelle has worked as a journalist, editor in chief and communications professional for more than 20 years with 12 years specializing in healthcare, including as editor in chief for the EndoNurse media brand. She’s the editor, ghost author and co-author of several books. Email		
					Senior Editor				
					Lisa Hewitt, MA				
		Lisa has had a long career as an editor, writer and designer, with an emphasis on medical content.		
					Art Director				
					Jason Garcia				
		Jason brings over 20 years of experience to EndoPro with a diversified portfolio in the industries of healthcare, finance, tourism and fashion as a designer and art director. Email		
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### Current Issue
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					September/October 2025				
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### News
News				
                        edit post
                        COVID Pandemic Linked to Surge in Digestive Disorders
                    by Michelle Beaver July 22, 2025 0 
                        A study led by Cedars-Sinai investigators uncovered a significant uptick in chronic digestive disorders, like irritable bowel syndrome, during the COVID-19 pandemic. The study findings, published in the peer-reviewed journal Neurogastroenterology &...
                        edit post
                        Online Course Offers Gastro Education Credits
                    by Michelle Beaver July 15, 2025 0 
                        The American Gastroenterological Association, in partnership with Clinical Care Options, LLC, and with support from an independent educational grant from Merck & Co., Inc., Rahway, NJ, USA, invites you to...
                        edit post
                        German Study Explores Endoscopy Waste
                    by Michelle Beaver July 15, 2025 0 
                        A multicenter observational study from the German healthcare system suggested that the annual waste generated by endoscopy in hospitals and outpatient settings in the country is roughly equivalent to the...
                        edit post
                        Anal Cancer Rising Among Older White and Hispanic Women
                    by Bill Eikost July 15, 2025 0 
                        BETHESDA, Maryland— Anal cancer has been steadily increasing in the United States, with the biggest jumps among older women, especially white and Hispanic women—a shift that challenges assumptions about high-risk...
                        edit post
                        FDA Blocks Imports of Certain Olympus Medical Devices from Japan
                    by Bill Eikost June 29, 2025 0 
                        Date: June 24, 2025 The U.S. Food and Drug Administration (FDA) has issued an import alert on select medical devices manufactured by Olympus Medical Systems Corporation in Japan. This action comes after repeated Quality System Regulation (QSR)...
                        edit post
                        Remembering Mick Reed (1945–2025)
                    by Bill Eikost June 23, 2025 0 
                        Dwight “Mick” Reed, beloved husband, father, grandfather, and founder of a national surgical repair company, passed away on Friday, June 20, 2025, at his home in Indian Lake, Ohio, surrounded...
                        edit post
                        Digestive Health Institute Uses New Screening Tool
                    by Michelle Beaver July 15, 2025 0 
                        NEWPORT BEACH, Calif.— Hoag Digestive Health Institute has become the first hospital facility in the United States to offer an esophageal cancer screening that is comprehensive, requires no sedation and...
                        edit post
                        Malaysian Endoscopy Team Completes 50 POEM Cases
                    by Michelle Beaver June 17, 2025 0 
                        KUALA LUMPUR, Malaysia—Pantai Hospital Kuala Lumpur announced in June that its staff members have successfully performed 50 peroral endoscopic myotomy (POEM) procedures since the service was introduced in 2020. POEM...
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					Adjustable Height Scope Reprocessing Sinks

### Home
edit post
                            Articles
                            Interviewing Patients
                             July 4, 2025
                        edit post
                            Articles
                            New Companies, New Products
                             July 4, 2025
                        edit post
                            Articles
                            Weight Management and Endoscopy
                             July 4, 2025
                        edit post
                            Articles
                            An Alternative to Plastic
                             July 3, 2025
                        edit post
                            Articles
                            Financial Literacy for Nurses
                             July 3, 2025
                        edit post
                            Articles
                            Flexible Endoscope Cleaning
                             July 3, 2025
                        edit post
                            Articles
                            ‘Levity Helps Keep Us Grounded’
                             July 18, 2025
                        edit post
                            Articles
                            Bleeding at the NIH
                             July 3, 2025
					ARTICLES				
                        edit post
                        Interviewing Patients
                    by Bill Eikost July 4, 2025 0 
                        A patient just walked in and gave you that laundry list of issues. You might become frustrated and think, “Where do I start with all the information?” I’ve been having...
                        edit post
                        New Companies, New Products
                    by Bill Eikost July 4, 2025 0 
                        We’re all familiar with the most massive, long-standing companies that are bedrocks of the endoscopy and processing industries, and we’re familiar with some smaller names that have been around a...
                        edit post
                        Weight Management and Endoscopy
                    by Bill Eikost July 4, 2025 0 
                        In this article we’ll examine the role of endoscopy in weight management and how to provide insights and strategies for working with patients on weight-related health issues. As a seasoned...
                        edit post
                        An Alternative to Plastic
                    by Bill Eikost July 3, 2025 0 
                        Plastics. They’re everywhere. And it’s not good. In fact, it’s very, very bad. These days there’s a lot of erroneous “health” information out there, and it’s hard sometimes to know...
                        edit post
                        Financial Literacy for Nurses
                    by Bill Eikost July 3, 2025 0 
                        For America’s 4.3 million registered nurses, financial advice that caters to traditional workers often falls short. Personal finance recommendations are typically designed for individuals with 9-to-5 jobs, stable income streams...
                     Load More
																					Celebrating 10 years in support of the endoscopy community
					Adjustable Height Scope Reprocessing Sinks				
					Adjustable Height Scope Reprocessing Sinks				
		 Sign Up For Our Newsletter
Subscribe to our mailing list to receive updates directly to your inbox!   
Leave this field empty if you're human: 		
					NEWS				
                        edit post
                        COVID Pandemic Linked to Surge in Digestive Disorders
                    by Michelle Beaver July 22, 2025 0 
                        A study led by Cedars-Sinai investigators uncovered a significant uptick in chronic digestive disorders, like irritable bowel syndrome, during the COVID-19 pandemic. The study findings, published in the peer-reviewed journal Neurogastroenterology &...
                        edit post
                        Online Course Offers Gastro Education Credits
                    by Michelle Beaver July 15, 2025 0 
                        The American Gastroenterological Association, in partnership with Clinical Care Options, LLC, and with support from an independent educational grant from Merck & Co., Inc., Rahway, NJ, USA, invites you to...
                        edit post
                        German Study Explores Endoscopy Waste
                    by Michelle Beaver July 15, 2025 0 
                        A multicenter observational study from the German healthcare system suggested that the annual waste generated by endoscopy in hospitals and outpatient settings in the country is roughly equivalent to the...
                        edit post
                        Anal Cancer Rising Among Older White and Hispanic Women
                    by Bill Eikost July 15, 2025 0 
                        BETHESDA, Maryland— Anal cancer has been steadily increasing in the United States, with the biggest jumps among older women, especially white and Hispanic women—a shift that challenges assumptions about high-risk...
                        edit post
                        FDA Blocks Imports of Certain Olympus Medical Devices from Japan
                    by Bill Eikost June 29, 2025 0 
                        Date: June 24, 2025 The U.S. Food and Drug Administration (FDA) has issued an import alert on select medical devices manufactured by Olympus Medical Systems Corporation in Japan. This action comes after repeated Quality System Regulation (QSR)...
                        edit post
                        Remembering Mick Reed (1945–2025)
                    by Bill Eikost June 23, 2025 0 
                        Dwight “Mick” Reed, beloved husband, father, grandfather, and founder of a national surgical repair company, passed away on Friday, June 20, 2025, at his home in Indian Lake, Ohio, surrounded...
                        edit post
                        Digestive Health Institute Uses New Screening Tool
                    by Michelle Beaver July 15, 2025 0 
                        NEWPORT BEACH, Calif.— Hoag Digestive Health Institute has become the first hospital facility in the United States to offer an esophageal cancer screening that is comprehensive, requires no sedation and...
                        edit post
                        Malaysian Endoscopy Team Completes 50 POEM Cases
                    by Michelle Beaver June 17, 2025 0 
                        KUALA LUMPUR, Malaysia—Pantai Hospital Kuala Lumpur announced in June that its staff members have successfully performed 50 peroral endoscopic myotomy (POEM) procedures since the service was introduced in 2020. POEM...
                     Load More
                     PRODUCT LOCATOR
                        edit post
                        New Companies, New Products
                    by Bill Eikost July 4, 2025 0 
                        We’re all familiar with the most massive, long-standing companies that are bedrocks of the endoscopy...
                        edit post
                        Probiotic Breakthrough Tackles Lactose Digestion Issues
                    by Michelle Beaver June 10, 2025 0 
                        Makers of the product Bactose are calling attention to a health issue that affects millions—especially...
                        edit post
                        Endoscopy Devices Market Growing Exponentially
                    by Michelle Beaver June 5, 2025 0 
                        According to a new report published by Polaris Market Research, the endoscopy devices market size...
                        edit post
                        Olympus Launches New Endoscope Drying Cabinet
                    by Michelle Beaver July 15, 2025 0 
                        Olympus Corp.—a global medical technology company—in late May announced the launch of the ScopeLocker Air...
                     Load More
					More news				
                        Shore Surgery Specialist Day Hospital Selects Provation® to Streamline Endoscopy Documentation and Advance Quality Improvement
                    by Sami Ernster 2025-07-17
                        Shore Surgery adopts Provation to streamline endoscopy documentation, boost audit capabilities, and support quality improvement across its network.
                        BRI exchanges share healthcare expertise
                    by 董森河 2025-07-16
                        Despite the air conditioner being on full blast to counter the sweltering heat, sweat droplets lingered on the foreheads of…
                        New modular endoscopy centre being built at Poole Hospital
                    by Deb Gayen 2025-07-15
                        Premier Modular and P+HS Architects start building a new modular endoscopy centre at Poole Hospital for University Hospitals Dorset, boosting…
                        New modular endoscopy centre being built at Poole Hospital
                    by Deb Gayen 2025-07-15
                        Premier Modular and P+HS Architects start building a new modular endoscopy centre at Poole Hospital for University Hospitals Dorset, boosting…
                        Industry partnership to deliver new endoscopy facility at Poole Hospital
                    by Insider Media 2025-07-14
                        Offsite manufacturer Premier Modular and P+HS Architects have partnered to bring forward a new modular endoscopy centre, with the first…
                        Researchers Detail Alarming Rise in GI Cancers Among Young People
                     2025-07-18
                        (MedPage Today) -- Early-onset gastrointestinal (GI) cancers are on the rise globally, and represent the most rapidly increasing early-onset cancer…
                        Surgery, Ablation Lead to Similar Outcomes for Small Liver Tumors
                     2025-07-18
                        (MedPage Today) -- Surgery and ablation for small liver tumors led to similar outcomes in a large study from Japan.…
                        Duchenne Gene Therapy Will Undergo Changes After Patient Deaths
                     2025-07-17
                        (MedPage Today) -- At the FDA's request, delandistrogene moxeparvovec (Elevidys), the only approved gene therapy for Duchenne muscular dystrophy, will…
                        GLP-1 Drugs Linked to GERD; Best Upfront Approach for H. Pylori? AI in Colonoscopy
                     2025-07-17
                        (MedPage Today) -- In patients with type 2 diabetes, GLP-1 receptor agonists were associated with a higher risk for gastroesophageal…
                        Nausea Drug Helped Kids After ED Visits for Gastroenteritis-Related Vomiting
                     2025-07-16
                        (MedPage Today) -- Ondansetron reduced the risk of recurrent gastroenteritis and vomiting when prescribed to children at discharge from emergency…


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