Routine pre-transplant evaluations for heart or lung recipients often include upper and lower gastrointestinal endoscopies. However, given that these patients frequently have significant and multiple comorbidities, the risk-benefit ratio of endoscopy with sedation remains uncertain.

We conducted a retrospective chart review of all patients who underwent esophagogastroduodenoscopy (EGD) and/or colonoscopy as part of the pre-transplant evaluation for heart (HTX) or lung transplantation (LuTX) at our center over a 10-year period. All procedures were performed with either anesthesiologist-assisted sedation or general anesthesia (72%) or physician-assisted sedation (28%). The primary outcomes included the prevalence of pre/neoplastic lesions and the rate of adverse events, classified according to the American Society of Gastrointestinal Endoscopy.

A total of 315 patients (70% male, median age 55 years) were included, with ASA grades 3 (31%) and 4 (69%). Of these, 90% underwent both EGD and colonoscopy. While no neoplasia or findings relevant to transplantation were detected on EGD, a single rectal malignant pedunculated polyp was identified and curatively removed via colonoscopy (G2 pT1 L0 V0 R0). The adenoma detection rate during colonoscopy was 25%, including a 7% rate of advanced adenomas, with six additional lesions (< 10 mm) exhibiting high-grade dysplasia. Conversely, severe adverse events occurred in 2.5% of cases, involving both cardiovascular and colonoscopy-related complications. These included two cases of severe hypotension and bradyarrhythmia requiring cardiovascular resuscitation, with one resulting in death (0.3% mortality). Additionally, one splenic rupture, two colonic perforations, and two cases of severe post-polypectomy bleeding were observed.

The routine requirement for upper and lower gastrointestinal endoscopy as a screening measure before heart or lung transplantation should be reconsidered due to its unfavorable risk-benefit profile. An individualized approach should be taken.

The carcinogenesis of colorectal cancer is well understood. Adenomas are the precursor lesions in about 70% of cases, highlighting the importance of screening programs.

The aim of this study was to analyze the effectiveness of colonoscopy examinations performed in a private tertiary service by calculating the polyp detection rate (PDR) and adenoma detection rate (ADR) and comparing these rates with literature data.

This retrospective observational study evaluated colonoscopies performed at Hospital Centro Médico de Campinas between 2018 and 2020. It assessed the indications and complications of colonoscopy, sex, age group, bowel preparation, cecal intubation rate, ADR, PDR, and advanced adenoma detection rate (AADR).

During the period, 3,686 colonoscopies were performed, and 3,076 were included in the analysis. The mean patient age was 57.2 years, and most patients were female (53.5%). Complications occurred in 39 colonoscopies (1.3%), with bleeding in six cases and perforation in one case. Tubular adenoma was the most prevalent histological subtype found in 20% of tests and in 62.7% of those with positive findings. The PDR was 23% and significantly increased with advancing age (p<0.01). The ADR was 20% and also significantly increased with age (p<0.001). This rate was higher in men (27%). The AADR was 4%.

Colonoscopy is an effective polyp detection method, and the PDR was higher in men and significantly increased with age. The ADR and AADR were comparable to the literature data.

Screening colonoscopy is often performed on patients who are younger or older than the ages specified in national guidelines or at shorter intervals than recommended. The annual incidence of harms associated with overuse of screening colonoscopy in the U.S. is not known. This study estimated the incidence of low-value screening colonoscopies annually in the U.S. and the number of preventable harms associated with them.

The 2018 National Health Interview Survey was used to estimate the number of annual screening colonoscopies. Rates of colonoscopy overuse and serious (bleeding and bowel perforation) and minor harms were drawn from 3 recent systematic reviews.

Approximately 12.4 million screening colonoscopies were completed in the U.S. in 2018. Given the credible range of overuse rates of screening colonoscopy, between 2.1 and 3.2 million low-value colonoscopies occur per year. Applying the credible ranges identified for serious and minor harms secondary to screening colonoscopy resulted in an estimated annual incidence of serious harm from unnecessary colonoscopies ranging from 9,055 to 11,874. The estimate for minor harms ranged from 359,5790 to 1,566,846.

In the U.S., screening colonoscopies are often completed at intervals and in populations that are inconsistent with national recommendations, resulting in unnecessary serious and minor harm. Although individual risk is relatively low, the large number of nonindicated screening colonoscopies results in large numbers of adverse events that are preventable with better adherence to recommendations.

Colonoscopy-based surveillance to prevent colorectal cancer (CRC) causes substantial burden for patients and health care. Stool tests may help to reduce surveillance colonoscopies by limiting colonoscopies to individuals at increased risk of advanced neoplasia.

This cross-sectional observational study included individuals aged 50-75 years with surveillance indication. Before bowel preparation, participants collected samples for a multitarget stool DNA test and 2 fecal immunochemical tests (FITs). Test accuracy was calculated for all surveillance indications. For the post-polypectomy indication only, which is the most common and is associated with a relatively low CRC risk, long-term impact of stool-based surveillance was evaluated with the Adenoma and Serrated Pathway to Colorectal Cancer (ASCCA) model. Stool-based strategies were simulated to tune each test's positivity threshold to obtain strategies at least as effective as colonoscopy surveillance.

There were 3453 individuals with results for all stool tests and colonoscopy; 2226 had previous polypectomy, 1003 had previous CRC, and 224 had a familial risk. Areas under the receiver operating characteristic curve for advanced neoplasia were 0.72 (95% CI, 0.69-0.75) for the multitarget stool DNA test, 0.61 (95% CI, 0.58-0.64) for the FIT OC-SENSOR (Eiken Chemical Co, Tokyo, Japan) and 0.59 (95% CI, 0.56-0.61) for the FIT FOB-Gold (Sentinel, Milan, Italy). Stool-based post-polypectomy surveillance strategies at least as effective as colonoscopy surveillance reduced the number of colonoscopies by 15%-41% and required 5.6-9.5 stool tests over a person's lifetime. Multitarget stool DNA-based surveillance was more costly than colonoscopy surveillance, whereas FIT-based surveillance saved costs.

This study found that stool-based post-polypectomy surveillance strategies can be safe and cost-effective, with potential to reduce the number of colonoscopies by up to 41%.

gov, Number: NCT02715141.

Patients undergoing evaluation for a heart transplant are frequently on inotropic medications or mechanical circulatory support (MCS) devices, which places them at a higher risk for anesthesia-related complications. These patients often require colonoscopies for bleeding or screening purposes, but there are limited data on the safety and outcomes of colonoscopy in this setting.

This is a retrospective, two-center study between the years 2015 and 2021 of patients with heart failure who subsequently underwent a heart transplant. To be included in the study, patients were required to be on advanced heart failure therapies at the time of colonoscopy. Advanced heart failure therapies were defined as requiring inotropes (milrinone or dobutamine), vasopressors (norepinephrine or vasopressin), or MCS such as an impella, left ventricular assist device (LVAD), intra-aortic balloon pump (IABP), or extra-corporeal membrane oxygenation (ECMO). Indications for colonoscopy, adequacy of bowel preparation, and complications were reported.

A total of 92 patients were included in the study. The most common indication was colon cancer screening (67%), and the remainder were performed due to gastrointestinal bleeding. An inadequate bowel preparation was reported on 20% of patients, but the cecum was reached in all of them. There was no association between the inadequacy of bowel preparation and the presence of MCS (20% vs. 17%, p value 0.67). In colonoscopies performed for screening, 8% (5/62) of patients were found to have an advanced adenoma. In colonoscopies performed for bleeding, 17% (5/30) had a source that required therapeutic intervention and use of hemostatic clips was the preferred modality. Only four patients had a complication of bleeding requiring clips after polypectomy during the index procedure, with no anesthesia-related adverse events (such as hypotension, arrhythmias, or cardiac arrest) or addition of inotropes, vasopressors, or MCS.

Colonoscopy in patients on advanced heart failure therapies is acceptable with not only a low rate of complications but also a high rate of inadequate bowel preparation.

To estimate the benefits, burden, and harms of implementing computer aided detection (CADe) of polyps in colonoscopy of population based screening programmes for colorectal cancer.

Microsimulation modelling study.

Cost effectiveness working package in the OperA (optimising colorectal cancer prevention through personalised treatment with artificial intelligence) project. A parallel guideline committee panel (BMJ Rapid recommendation) was consulted in defining the screening interventions and selection of outcome measures.

Four cohorts of 100 000 European individuals aged 60-69 years.

The intervention was one screening of colonoscopy and a screening of colonoscopy after faecal immunochemical test every other year with CADe. The comparison group had the same screening every other year without CADe.

Benefits (colorectal cancer incidence and death), burden (surveillance colonoscopies), and harms (colonoscopy related adverse events) over 10 years were measured. The certainty in each outcome was assessed by use of the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach.

For 100 000 individuals participating in colonoscopy screening, 824 (0.82%) were diagnosed with colorectal cancer within 10 years without CADe versus 713 (0.71%) with CADe (risk difference -0.11% (95% CI -0.43% to 0.21%)). For faecal immunochemical test screening colonoscopy, the risk was 5.82% (n=5820) without CADe versus 5.77% (n=5770) with CADe (difference -0.05% (-0.33% to 0.15%)). The risk of surveillance colonoscopy increased from 26.45% (n=26 453) to 32.82% (n=32 819) (difference 6.37% (5.8% to 6.9%)) for colonoscopy screening and from 52.26% (n=52 263) to 53.08% (n=53 082) (difference 0.82% (0.38% to 1.26%)) for faecal immunochemical test screening colonoscopy. No significant differences were noted in adverse events related to the colonoscopy between CADe and no CADe. The model estimates were sensitive to the assumed effects of screening on colorectal cancer risk and of CADe on adenoma detection rates. All outcomes were graded as low certainty.

With low certainty of evidence, adoption of CADe in population based screening provides small and uncertain clinical meaningful benefit, no incremental harms, and increased surveillance burden after screening.

Mesenteric laceration after screening colonoscopy is a rare and fatal complication. This case reported a giant hematoma due to a small intestinal mesenteric laceration after a screening colonoscopy.

A 56-year-old woman complained of persistent dramatic abdominal pain after the screening colonoscopy. This patient has appendectomy, rheumatic heart disease, IgG4-related disease, type 2 diabetes mellitus, and coronary atherosclerotic heart disease. Blood tests showed hemoglobin concentration sharply fell to 87 g/L and computed tomography scans confirmed a 16.4 cm × 6.1 cm × 9.5 cm hematoma abdominal hematoma near the small intestine. Digital subtraction angiography consistently showed rough and disordered the fourth group of the superior mesenteric artery. The main diagnosis was mesenteric laceration of the small intestine following colonoscopy. The patient was treated with fasting, gastrointestinal decompression, rehydration, inhibition of gastric acid, and meropenem to fight infection, 4 U suspended red blood cells and 400 mL fresh frozen plasma. Finally, this patient was discharged after conservative treatment, and the abdominal hematoma was significantly shrunk after 3 months.

Anticoagulants, a history of previous abdominal surgery, and IgG-RD leading to abdominal fibrosis were possible risk factors for mesenteric laceration. When the patient's condition is complex and has no absolute indication for surgery, conservative management could be appropriately considered.

We reported a case of abdominal hematoma due to colonoscopy. The successful conservative therapy may provide a novel experience for intra-abdominal hematoma treatment.

Rural patients experience a higher incidence of and mortality from colorectal cancer. Ensuring high-quality screening is essential to address these disparities.

To investigate whether socioecological determinants of health are associated with colonoscopy quality in rural Alabama.

Retrospective review.

Data across 3 rural hospitals in Alabama from August 2021 to July 2023.

We included adults (aged 18 years or older) who underwent screening or diagnostic colonoscopy and completed a validated survey that measures socioecological determinants of health.

Primary outcomes included bowel preparation quality, cecal intubation, and adenoma detection rate. We linked the survey responses to these quality metrics to identify factors associated with outcomes. Analyses included the χ 2 , Fisher exact, and Kruskal-Wallis rank-sum tests, with a p value of < 0.05 considered statistically significant.

The 84 patients surveyed were 66.7% men, 50.0% Black, and had a median age of 64 years. Optimal bowel preparation was present in 88.0%, successful cecal intubation was observed in 89.3%, and the overall adenoma detection rate was 45.8%. Patients with suboptimal bowel preparation described lower rates of internet access (60.0% vs 87.4%, p < 0.05), more difficulty in understanding written information (30.0% vs 1.4%, p < 0.05), and lacked a sense of responsibility for their health (30.0% vs 51.4%, p < 0.05) compared to those having optimal bowel preparation. Those with unsuccessful cecal intubations had lower physician trust (55.6% vs 73.3%, p < 0.05), whereas patients with successful cecal intubations were more confident in preventing health-related problems (53.3% vs 33.3%, p < 0.05) and had a more supportive social environment (72.0% vs 66.7%, p < 0.05).

Retrospective design and small sample size limiting multivariable analyses.

In rural Alabama, lower health literacy, internet access, and physician trust were associated with low-quality colonoscopy, whereas a higher patient sense of responsibility and a supportive social environment were associated with higher-quality metrics. These findings identify potential targets for improving colonoscopy quality in rural settings. See Video Abstract.

ANTECEDENTES:Los pacientes rurales sufren una mayor incidencia y mortalidad por cáncer colorrectal. Garantizar un cribado de alta calidad es esencial para abordar estas disparidades.OBJETIVO:Investigar si los determinantes socioecológicos de la salud están asociados con la calidad de la colonoscopia en las zonas rurales de Alabama.DISEÑO:Revisión retrospectiva.LUGAR:Datos a través de tres hospitales rurales en Alabama desde agosto de 2021 hasta julio de 2023.PACIENTES:Se incluyeron adultos (≥18 años) que se sometieron a colonoscopia de cribado o diagnóstica y completaron una encuesta validada que mide los determinantes socioecológicos de la salud.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios incluyeron la calidad de la preparación intestinal, la canulazion cecal y la tasa de detección de adenomas. Vinculamos las respuestas de la encuesta a estas métricas de calidad para identificar factores asociados con los resultados. Los análisis incluyeron las pruebas χ2 , exacta de Fisher y de suma de rangos de Kruskal-Wallis, considerándose estadísticamente significativa una p < 0,05.RESULTADOS:Los 84 pacientes encuestados eran un 66,7% varones, un 50,0% de raza negra y tenían una edad media de 64 años. La preparación intestinal óptima estuvo presente en el 88,0%, el 89,3% tuvo canulazion cecales exitosas, y la tasa general de detección de adenomas fue del 45,8%. Los pacientes con una preparación intestinal subóptima describieron tasas más bajas de acceso a Internet (60,0% frente a 87,4%, p < 0,05), más dificultades para comprender la información escrita (30,0% frente a 1,4%, p < 0,05) y carecían de sentido de la responsabilidad por su salud (30,0% frente a 51,4%, p < 0,05) en comparación con los que tenían una preparación intestinal óptima. Los pacientes con canulaziones cecales fallidas tenían menos confianza en el médico (55,6% frente a 73,3%, p < 0,05), mientras que los pacientes con canulaziones cecales satisfactorias tenían más confianza en la prevención de problemas relacionados con la salud (53,3% frente a 33,3%, p < 0,05) y contaban con un entorno social más favorable (72,0% frente a 66,7%, p < 0,05).LIMITACIONES:El diseño retrospectivo y el pequeño tamaño de la muestra limitan los análisis multivariables.CONCLUSIÓN:En las zonas rurales de Alabama, la alfabetización sanitaria, el acceso a Internet y la confianza en el médico se asociaron con una colonoscopia de baja calidad, mientras que un mayor sentido de la responsabilidad del paciente y un entorno social de apoyo se asociaron con métricas de mayor calidad. Estos hallazgos identifican objetivos potenciales para mejorar la calidad de la colonoscopia en entornos rurales. (Traducción-Dr Yolanda Colorado ).

To investigate the application of the three-compartment restriction spectrum imaging (RSI) model, diffusion kurtosis imaging (DKI), and diffusion-weighted imaging (DWI) in predicting Ki-67 status in rectal carcinoma.

A total of 80 rectal carcinoma patients, including 47 high-proliferation (Ki-67 > 50%) cases and 33 low-proliferation (Ki-67 ≤ 50%) cases, underwent pelvic MRI were enrolled. Parameters derived from RSI (f1, f2, and f3), DKI (MD and MK), and DWI (ADC) were calculated and compared between the two groups. Logistic regression (LR) analysis was conducted to identify independent predictors and assess combined diagnosis. Area under the receiver operating characteristic curve (AUC), DeLong analysis, and calibration curve analyses were performed to evaluate diagnostic performance.

The patients with high-proliferation rectal carcinoma exhibited significantly higher f1 and MK values and significantly lower ADC, MD, f2, and f3 values than those with low-proliferation rectal carcinoma (P < 0.05). LR analysis showed that MD, MK, and f2 were independent predictors for Ki-67 status in rectal carcinoma. Moreover, the combination of these three parameters achieved an optimal diagnostic efficacy (AUC = 0.877, sensitivity = 80.85%, specificity = 84.85%) that was significantly better than that obtained using ADC (AUC = 0.783, Z = 2.347, P = 0.019), f2 (AUC = 0.732, Z = 2.762, P = 0.006), and f3 (AUC = 0.700, Z = 3.071, P = 0.002). The combined diagnosis also showed good performance (AUC = 0.859) in the internal validation analysis based on 1000 bootstrap samples, while the calibration curve demonstrated that the combined diagnosis provided good stability.

RSI, DKI, and DWI can effectively differentiate between patients with high- and low-proliferation rectal carcinoma. Furthermore, the MD, MK, and f2 imaging parameters may be a novel and promising combination biomarker for examining Ki-67 status in rectal carcinoma.

The positivity thresholds of faecal immunochemical testing (FIT) in colorectal cancer (CRC) screening vary between countries.

To explore the trade-off between colonoscopies performed, adverse events and lesions detected at different FIT thresholds in a Norwegian CRC screening trial.

We included first participation in biennial FIT screening for 47,265 individuals aged 50-74 years. Individuals with FIT > 15 μg Hb/g faeces were referred for colonoscopy. We estimated the number of colonoscopies, adverse events, screen-detected CRCs, advanced adenomas and serrated lesions expected at FIT thresholds currently or recently used in other European countries ranging between 20 and 150 μg/g.

At the 15 μg/g threshold (Norway), 3705 participants underwent colonoscopy, of whom 203 had CRC, 1119 advanced adenomas and 256 advanced serrated lesions. Using a 47 μg/g threshold, 1826 (49.3%) individuals would have undergone colonoscopy, and 154 (75.9%) would have been diagnosed with CRC, 702 (62.7%) with advanced adenoma and 128 (50.0%) with advanced serrated lesion compared to the 15 μg/g threshold. At 150 μg/g, the corresponding figures would have been 838 (22.6%) undergoing colonoscopy, 114 (56.2%) with CRC, 345 (30.8%) advanced adenoma and 54 (21.1%) advanced serrated lesions. The detection rate of stage I CRC was 0.22% at 15 μg/g and 0.11% at 150 μg/g. Post-colonoscopy bleeding rates were 0.8% and 1.7%, respectively.

Increasing the FIT threshold reduces colonoscopy demand, but substantially decreases lesion detection and unfavourably changes CRC stage distribution. The risk of adverse events at colonoscopy increased with FIT threshold, requiring country-specific information on adverse events.

Clinicaltrials.gov identifier: NCT01538550.

Lynch syndrome (LS) is a hereditary autosomal dominant condition, with an increased lifetime risk of developing malignancies including colorectal cancer (CRC). Current guidelines differ in recommended colonoscopy-surveillance intervals from 1 to 2 years. Although colonoscopy is considered a safe procedure, there are risks of severe adverse events (SAEs), such as perforation and bleeding, as well as adverse events (AEs), such as abdominal discomfort and post-colonoscopy gastrointestinal infections. Colonoscopy-related bleeding and perforation rates have been reported 0.17% and 0.11%, respectively. However, there are insufficient data regarding complications of colonoscopy-surveillance for LS patients. This study aims to investigate the risk of AEs among LS patients during colonoscopy in the Stockholm region.

This retrospective cohort study includes 351 LS patients undergoing endoscopic surveillance at the Karolinska University Hospital, August 1989 - April 2021. Data from endoscopic surveillance colonoscopies were extracted from patients' medical records.

Of 1873 endoscopies in 351 LS patients, 12 complications (AEs) were documented within 30 days (0.64%) and with a total of 3 bleedings (SAEs, 0.16%). No perforations were identified.

Colonoscopy surveillance for LS patients shows a comparatively low risk of AEs per-examination. Colonoscopy complications per-patient, including both SAEs and AEs, show a significantly higher risk. Colonoscopy complications only including SAEs, show a comparatively low risk. Understanding the lifetime risk of surveillance-related colonoscopy complications is important when designing targeted surveillance programmes.

Colonoscopy-related adverse events increase the burden of colorectal cancer (CRC) screening. This cross-sectional study evaluates adverse events during and after colonoscopy in a large, randomised CRC screening trial in Norway comparing sigmoidoscopy to immunochemical testing for faecal blood.

We included all individuals who underwent colonoscopy at two screening centres between 2012 and 2020. From medical records, we retrieved data on adverse events during and within 30 days after colonoscopy and classified them according to the American Society for Gastrointestinal Endoscopy lexicon for endoscopic adverse events. Multivariable logistic regression models were fitted to identify risk factors for adverse events.

Of the 10 244 included individuals, 242 (2.4%) had at least one adverse event that was possibly, probably, or definitively related to the colonoscopy. 188 (1.8%) had mild adverse events, 50 (0.49%) had moderate, 3 (0.03%) had severe, and 1 had a fatal adverse event. The most frequent adverse events were lower gastrointestinal bleeding (0.86%), abdominal pain (0.48%), vasovagal reaction (0.39%), postpolypectomy syndrome (0.20%), and perforation (0.08%). 23 (0.22%) individuals had non-gastrointestinal adverse events. Risk factors associated with adverse events were older age, female sex, screening centre, anticoagulant therapy, number of polypectomies, size of lesion removed, presence of proximal lesion, and adenocarcinoma. Adverse event rates per endoscopist ranged from 0% to 4.9%.

Adverse events after colonoscopy of screening positives occurred in about 2 out of 100 procedures. Three-quarters of events were mild. Awareness of risk factors may help endoscopists to mitigate the risk.

NCT01538550.

Risk assessment is of paramount importance for the detection and treatment of colorectal cancer. We developed and validated a feature interpretability screening framework to identify high-risk populations and recommend colonoscopy for them.

We utilized a training cohort consisting of 1 252 605 participants who underwent colonoscopies in Shanghai from 2013 to 2015 to develop the screening framework. We incorporated Shapley additive explanation values into feature selection to provide interpretability for the framework. Two sampling methods were separately employed to mitigate potential model bias caused by class imbalance. Furthermore, we employed various machine learning algorithms to construct risk assessment models and compared their performance. We tested the screening models on an external validation cohort of 359 462 samples and conducted comprehensive evaluation and statistical analysis of the validation results.

The external validation results demonstrated that the models in the proposed framework achieved sensitivity over 0.734, specificity over 0.790, and area under the receiver operating characteristic curve ranging from 0.808 to 0.859. In the predictions of the best-performing model, the prevalence rates of colorectal cancer were 0.059% and 1.056% in the low- and high-risk groups, respectively. If colonoscopies were performed only on the high-risk group predicted by the model, only 14.36% of total colonoscopies would be needed to detect 74.86% of colorectal cancer cases.

We developed and validated a novel framework to identify populations at high risk for colorectal cancer. Those classified as high risk should undergo colonoscopy for further diagnosis.

This study aims to analyze the risk factors associated with delayed postoperative bleeding (DPPB) following colorectal polyp surgery, develop a dynamic nomogram and evaluate the model efficacy, provide a reference for clinicians to identify the patients at high risk of DPPB. Retrospective study was done on patients who underwent endoscopic colorectal polypectomy at the First Hospital of Lanzhou University from January 2020 to March 2023. Differences between the group with and without DPPB were compared, and independent risk factors for DPPB occurrence were identified through univariate analysis and combination LASSO and logistic regression. A dynamic nomogram was constructed based on multiple logistic regression to predict DPPB following colorectal polyp surgery. Model evaluation included receiver operating characteristic (ROC), Calibration curve, Decision curve analysis (DCA). DPPB occurred in 38 of the 1544 patients included. multivariate analysis showed that direct oral anticoagulants (DOACs), polyp location in the right hemi colon, polyp diameter, drink, and prophylactic hemoclips were the independent risk factors for DPPB and dynamic nomogram were established. Model validation indicated area under the ROC curve values of 0.936, 0.796, and 0.865 for the training set, validation set, and full set, respectively. The calibration curve demonstrated a strong alignment between the predictions of the column-line diagram model and actual observations. The decision curve analysis (DCA) displayed a significant net clinical benefit across the threshold probability range of 0-100%. The dynamic nomogram aids clinicians in identifying high-risk patients, enabling personalized diagnosis and treatment.

Avoidance of colonoscopy is often associated with fear, embarrassment, and disgust aroused in screening procedures. However, each emotion can be linked to different challenges faced by patients. More research is needed to evaluate and address the causes of these respective emotions.

The purpose of this study was to develop and assess the scales of three negative emotions (i.e., fear, embarrassment, and disgust) caused by specific issues in colonoscopy screening.

The measurement items were developed based on multiple common barriers in colonoscopy screening procedures. An online sample of 232 adults aged 45-75 was recruited from Amazon Mechanical Turk to test the scales. Explorative and confirmatory factor analyses were conducted to validate the measurement models.

Psychometric evidence demonstrated the factor structures of three negative emotions. Each emotional factor was caused by unique combinations of barriers in the preparation, screening, and recovery stages of colonoscopy. Most of the emotional factors were associated with attitudes and screening intention.

This study showed different dimensions of negative emotions and their underlying causes in colonoscopy. These findings will help assess specific causes of negative emotions in colonoscopy and develop effective interventions to improve screening uptake.

Colonoscopy is a widely used examination for colonic diseases with low risk. Hemoperitoneum due to injury of transverse mesocolon is an extremely rare but potentially lethal complication. We present a case of an elderly woman who complained of continuous abdominal pain after a colonoscopy, with progressive anemia. An emergency exploratory laparoscopy revealed a laceration of the transverse mesocolon. The underlying mechanism is unclear due to its rarity. Old age, atherosclerotic disease, the long operating time of colonoscopy, and manual compression on the abdomen during the procedure may be risk factors for transverse mesenteric laceration during colonoscopy.

The incidence and mortality of colorectal cancer (CRC) have decreased through regular screening colonoscopy, surveillance, and endoscopic treatment. However, CRC can still be diagnosed after negative colonoscopy. Such CRC is called interval CRC and accounts for 1.8-9.0% of all CRC cases. Most cases of interval CRC originate from missed lesions and incompletely resected lesions. Interval CRC can be minimized by improving the quality of colonoscopy. This has led to a growing interest in and demand for high-quality colonoscopy. It is important to reduce the risk of CRC and its associated mortality by improving the quality of colonoscopy. In this review article, we provide an overview of colonoscopy quality indicators, including bowel preparation adequacy, the cecal intubation rate, the adenoma detection rate, the colonoscopy withdrawal time, appropriate polypectomy, and complication of the procedure. Because colonoscopy is a highly endoscopist-dependent procedure, colonoscopists should be well-acquainted with quality indicators and strive to apply them in daily clinical practice for the prevention of CRC.

To estimate the impact on clinical outcomes and healthcare resource use from recommending that patients with 1-2 low-risk adenomas (LRAs) return to routine fecal immunochemical test (FIT) screening instead of surveillance colonoscopy, from a Canadian provincial healthcare system perspective.

The OncoSim-Colorectal microsimulation model simulated average-risk individuals eligible for FIT-based colorectal cancer (CRC) screening in Alberta, Canada. We simulated two surveillance strategies that applied to individuals with 1-2 LRAs (<10 mm) removed as part of the average risk CRC screening program: (a) Surveillance colonoscopy (status quo) and (b) return to FIT screening (new strategy); both at 5 years after polypectomy. A 75 ng/mL FIT positivity threshold was used in the base case. The simulations projected average annual CRC outcomes and healthcare resource use from 2023 to 2042. We conducted alternative scenarios and sensitivity analyses on key variables.

Returning to FIT screening (versus surveillance colonoscopy) after polypectomy was projected to have minimal impact on long-term CRC incidence and deaths (not statistically significant). There was a projected decrease of one (4%) major bleeding event and seven (5%) perforation events per year. There was a projected increase of 4800 (1.5%) FIT screens, decrease of 3900 (5.1%) colonoscopies, and a decrease of $3.4 million (1.2%) in total healthcare costs per year, on average. The annual colonoscopies averted and healthcare cost savings increased over time. Results were similar in the alternative scenarios and sensitivity analyses.

Returning to FIT screening would have similar clinical outcomes as surveillance colonoscopy but could reduce colonoscopy demand and healthcare costs.

Diagnostic colonoscopy plays a central role in colorectal cancer screening programs. We analyzed the risk factors for perforation during diagnostic colonoscopy and discussed the treatment outcomes.

We performed a retrospective analysis of risk factors and treatment outcomes of perforation during 74,426 diagnostic colonoscopies between 2013 and 2018 in a tertiary hospital.

A total of 19 perforations were identified after 74,426 diagnostic colonoscopies or sigmoidoscopies, resulting in a standardized incidence rate of 0.025% or 2.5 per 10,000 colonoscopies. The majority (15 out of 19, 79%) were found at the sigmoid colon and recto-sigmoid junction. Perforation occurred mostly in less than 1000 cases of colonoscopy (16 out of 19, 84%). In particular, the incidence of perforation was higher in more than 200 cases undergoing slightly advanced colonoscopy rather than beginners who had just learned colonoscopy. Old age (≥ 70 years), inpatient setting, low body mass index (BMI), and sedation status were significantly associated with increased risk of perforation. Nine (47%) of the patients underwent operative treatment and ten (53%) were managed non-operatively. Patients who underwent surgery were often diagnosed with delayed or concomitant abdominal pain. Perforations of rectum tended to be successfully treated with endoscopic clipping.

Additional precautions are required to prevent perforation in elderly patients, hospital settings, low BMI, sedated patients, or by a doctor with slight familiarity with endoscopies (but still insufficient experience). Endoscopic treatment should be actively considered if diagnosis is prompt, abdominal pain absent, and especially the rectal perforation is present.

Analyzing blood lipid and bile acid profile changes in colorectal cancer (CRC) patients. Evaluating the integrated model's diagnostic significance for CRC. Ninety-one individuals with colorectal cancer (CRC group) and 120 healthy volunteers (HC group) were selected for comparison. Serum levels of total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and apolipoproteins (Apo) A1, ApoA2, ApoB, ApoC2, and ApoC3 were measured using immunoturbidimetric and colorimetric methods. Additionally, LC-MS/MS was employed to detect fifteen bile acids in the serum, along with six tumor markers: carcinoembryonic antigen (CEA), carbohydrate antigens (CA) 125, CA19-9, CA242, CA50, and CA72-4. Group comparisons utilized independent sample t-tests and Mann-Whitney U tests. A binary logistic regression algorithm was applied to fit the indicators and establish a screening model; the diagnostic accuracy of individual Indicators and the model was analyzed using receiver operating characteristic (ROC) curves. The CRC group showed significantly lower levels in eight serum lipid indicators and eleven bile acids compared to the HC group (P < 0.05). Conversely, serum levels of TG, CA19-9, and CEA were elevated (P < 0.05). Among the measured parameters, ApoA2 stands out for its strong correlation with the presence of CRC, showcasing exceptional screening efficacy with an area under the curve (AUC) of 0.957, a sensitivity of 85.71%, and a specificity of 93.33%. The screening model, integrating ApoA1, ApoA2, lithocholic acid (LCA), and CEA, attained an impressive AUC of 0.995, surpassing the diagnostic accuracy of individual lipids, bile acids, and tumor markers. CRC patients manifest noteworthy alterations in both blood lipids and bile acid profiles. A screening model incorporating ApoA1, ApoA2, LCA, and CEA provides valuable insights for detecting CRC.

The number of elderly patients with ulcerative colitis (UC) has been increasing worldwide. Complications are common in elderly patients who undergo colonoscopy, raising doubts about whether colonoscopy should be performed in the same way in this age group as in younger patients. The aim of this study was to determine the safety of full bowel preparation and colonoscopy in elderly patients with UC.

We retrospectively reviewed a cohort of patients with UC who had visited any of the 12 hospitals and were registered in our inflammatory bowel disease database. We compared complications associated with colonoscopy and bowel preparation and relapse of UC after colonoscopy in 133 patients aged ≥65 years with UC (the elderly group) and 116 randomly selected patients aged <65 years with UC (the non-elderly group).

Nine elderly patients were not referred for colonoscopy by their physicians because of poor performance status or advanced age. There was no significant between-group difference in the complication rate (p = 0.57) or frequency of relapse of UC after colonoscopy (p = 0.67).

The findings of this study indicate that colonoscopy can be performed as safely in elderly patients with UC as in their younger counterparts. However, our results also indicate that colonoscopy is often avoided in elderly patients, possibly because of concerns about safety.

Hot snare polypectomy using blend or coagulation current is widely used; however, it causes deeper tissue heat injury, leading to adverse events. We hypothesized that hot polypectomy using low-power pure cut current (PureCut, effect 1 10 W) could reduce deeper tissue heat injury. We conducted animal experiments to evaluate the deeper tissue heat injury and conducted a prospective clinical study to examine its cutting ability.

In a porcine rectum, hot polypectomy using Blend current (EndoCut, effect 3 40 W) and low-power pure cut current was performed. The deepest part of heat destruction and thickness of the non-burned submucosal layer were evaluated histologically. Based on the results, we performed low-power pure cut current hot polypectomy for 10-14 mm adenoma. The primary endpoint was complete resection defined as one-piece resection with negative for adenoma in quadrant biopsies from the defect margin.

In experiments, all low-power pure-cut resections were limited within the submucosal layer whereas blend current resections coagulated the muscular layer in 13% (3/23). The remaining submucosal layer was thicker in low-power pure cut current than in blend current resections. In the clinical study, low-power pure-cut hot polypectomy removed all 100 enrolled polyps. For 98 pathologically neoplastic polyps, complete resection was achieved in 84 (85.7%, 95% confidence interval, 77-92%). The lower limit of the 95% confidence interval was not more than 15% below the pre-defined threshold of 86.6%. No severe adverse events occurred.

A novel low-power pure-cut hot polypectomy may be feasible for adenoma measuring 10-14 mm. (UMIN000037678).

Bowel preparation is considered as major obstacle before colonoscopy, and it is often reported as the most feared part of the procedure. The aim of this study is to determine the difference in efficacy between a split dose of PEG and the previous day regimen in cleaning the colon, using Boston bowel preparation scale. In addition, also to evaluate patient satisfaction regarding the modality of preparation.

The study included 200 hospitalized patients undergoing colonoscopy at Beirut hospitals between 2021 and 2023. One of the two regimens will be prescribed randomly to the patients before colonoscopy: 98 (49%) in Group A (patients treated with PEG preparation as a split dose for 2 days), and 102 (51%) in Group B (patients taking PEG preparation as a whole dose). Data was analyzed using SPSS version 25.

Patients were distributed between 105 (52.5%) males and 95 (47.5%) females. The top two indications for colonoscopy were bleeding (34%), change in bowel habits (constipation/diarrhea) (32%). Patients experienced adverse events noting cramps (48.5%), stomach ache (32%), headache (31%), vomiting (53%), nausea (53%), sleep disturbance (27%), bloating (26.5%), and malaise (26%). A statistically significant difference (p = 0.040) was detected in sleep disturbance: 20.4% of patients in group A and 33.3% of patients in group B. The average satisfaction score was 3.02 ± 1.03 over 4 (Group A) and 3.04 ± 0.99 over 4 (Group B) (p = 0.896). The average BBPS was 8.07 ± 1.14 (Group A) and 8.28 ± 1.0 (Group B) (p = 0.162).

The two administrations were almost similar in term of satisfaction and BBPS. As multiple factors like age, sexe, comorbidities may contribute in altering how much a given drug is safe and efficace, more research is needed to choose the best 3regimen for each patient.

This study aimed to identify the most cost-effective strategy for colorectal cancer screening using the fecal immunochemical test (FIT), focusing on screening initiation age in Korea.

We designed Markov simulation models targeting individuals aged 40 years or older. Twelve strategies combining screening initiation ages (40, 45, or 50 years old), termination ages (80 or no limit), and intervals (1 or 2 years) were modeled, and the most cost-effective strategy was selected. The robustness of the results was confirmed using one-way and probabilistic sensitivity analyses. Furthermore, the cost-effectiveness of the qualitative and quantitative FIT methods was verified using scenario analysis.

The 2-year interval strategy with a screening age range of 45-80 years was the most cost-effective (incremental cost-utility ratio = KRW 7,281,646/quality adjusted life years). The most sensitive variables in the results were transition rate from advanced adenoma to local cancer and discount rate. The uncertainty in the model was substantially low. Moreover, strategies starting at the age of 40 years were also cost-effective but considered suboptimal. The scenario analysis showed that there was no significant difference in cost-effectiveness between strategies with various relative screening ratio of quantitative and qualitative method.

The screening method for advancing the initiation age, as presented in the 2015 revised national screening recommendations, was superior regarding cost-effectiveness. This study provides a new paradigm for the development of a national cancer screening system in Korea, which can be utilized as a scientific basis for economic evaluations.

Colorectal cancer screening programmes (CRCSPs) are implemented worldwide despite recent evidence indicating more physical harm occurring during CRCSPs than previously thought. Therefore, we aimed to review the evidence on physical harms associated with endoscopic diagnostic procedures during CRCSPs and, when possible, to quantify the risk of the most serious types of physical harm during CRCSPs, i.e. deaths and cardiopulmonary events (CPEs).

Systematic review with descriptive statistics and random-effects meta-analyses of studies investigating physical harms following CRCSPs. We conducted a systematic search in the literature and assessed the risk of bias and the certainty of the evidence.

We included 134 studies for review, reporting findings from 151 unique populations when accounting for multiple screening interventions per study. Physical harm can be categorized into 17 types of harm. The evidence was very heterogeneous with inadequate measurement and reporting of harms. The risk of bias was serious or critical in 95% of assessments of deaths and CPEs, and the certainty of the evidence was very low in all analyses. The risk of death was assessed for 57 populations with large variation across studies. Meta-analyses indicated that 3 to 23 deaths occur during CRCSPs per 100,000 people screened. Cardiopulmonary events were assessed for 55 populations. Despite our efforts to subcategorize CPEs into 17 distinct subtypes, 41% of CPE assessments were too poorly measured or reported to allow quantification. We found a tendency towards lower estimates of deaths and CPEs in studies with a critical risk of bias.

Deaths and CPEs during CRCSPs are rare, yet they do occur during CRCSPs. We believe that our findings are conservative due to the heterogeneity and low quality of the evidence. A standardized system for the measurement and reporting of the harms of screening is warranted.

PROSPERO Registration number CRD42017058844.

Randomized clinical screening trials have shown that sigmoidoscopy screening reduces colorectal cancer (CRC) incidence and mortality. Colonoscopy has largely replaced sigmoidoscopy for CRC screening, but long-term results from randomized trials on colonoscopy screening are still lacking.

To estimate the additional screening benefit of colonoscopy compared with sigmoidoscopy.

This comparative effectiveness simulation study pooled data on 358 204 men and women randomly assigned to sigmoidoscopy screening or usual care in 4 randomized sigmoidoscopy screening trials conducted in Norway, Italy, the US, and UK with inclusion periods in the years 1993 to 2001. The primary analysis of the study was conducted from January 19 to December 30, 2021.

Invitation to endoscopic screening.

Primary outcomes were CRC incidence and mortality. Using pooled 15-year follow-up data, colonoscopy screening effectiveness was estimated assuming that the efficacy of colonoscopy in the proximal colon was similar to that observed in the distal colon in the sigmoidoscopy screening trials. The simulation model was validated using data from Norwegian participants in a colonoscopy screening trial.

This analysis included 358 204 individuals (181 971 women [51%]) aged 55 to 64 years at inclusion with a median follow-up time ranging from 15 to 17 years. Compared with usual care, colonoscopy prevented an estimated 50 (95% CI, 42-58) CRC cases per 100 000 person-years, corresponding to 30% incidence reduction (rate ratio, 0.70 [95% CI, 0.66-0.75]), and prevented an estimated 15 (95% CI, 11-19) CRC deaths per 100 000 person-years, corresponding to 32% mortality reduction (rate ratio, 0.68 [95% CI, 0.61-0.76]). The additional benefit of colonoscopy screening compared with sigmoidoscopy was 12 (95% CI, 10-14) fewer CRC cases and 4 (95% CI, 3-5) fewer CRC deaths per 100 000 person-years, corresponding to percentage point reductions of 6.9 (95% CI, 6.0-7.9) for CRC incidence and 7.6 (95% CI, 5.7-9.6) for CRC mortality. The number needed to switch from sigmoidoscopy to colonoscopy screening was 560 (95% CI, 486-661) to prevent 1 CRC case and 1611 (95% CI, 1275-2188) to prevent 1 CRC death.

The findings of this comparative effectiveness study assessing long-term follow-up after CRC screening suggest that there was an additional preventive effect on CRC incidence and mortality associated with colonoscopy screening compared with sigmoidoscopy screening, but the additional preventive effect was less than what was achieved by introducing sigmoidoscopy screening where no screening existed. The results probably represent the upper limit of what may be achieved with colonoscopy screening compared with sigmoidoscopy screening.

Colon cancer is the third most common malignancy in Canada. Computed tomography colonography (CTC) provides a creditable and validated option for colon screening and assessment of known pathology in patients for whom conventional colonoscopy is contraindicated or where patients self-select to use imaging as their primary modality for initial colonic assessment. This updated guideline aims to provide a toolkit for both experienced imagers (and technologists) and for those considering launching this examination in their practice. There is guidance for reporting, optimal exam preparation, tips for problem solving to attain high quality examinations in challenging scenarios as well as suggestions for ongoing maintenance of competence. We also provide insight into the role of artificial intelligence and the utility of CTC in tumour staging of colorectal cancer. The appendices provide more detailed guidance into bowel preparation and reporting templates as well as useful information on polyp stratification and management strategies. Reading this guideline should equip the reader with the knowledge base to perform colonography but also provide an unbiased overview of its role in colon screening compared with other screening options.

Colonoscopy is a crucial procedure for various clinical purposes, including screening for colorectal cancer. Adequate bowel preparation is essential for its success. Poor bowel preparation can lead to bad outcomes. An objective assessment of bowel preparation quality is typically only possible after the colonoscope is inserted. This study aimed to objectively correlate the clarity of last rectal effluent, directly collected in a transparent container, with the quality of bowel preparation, and compare it with patient-reported descriptions.

This prospective, single-centre, case-control study obtained ethical clearance and included patients aged >18 years undergoing colonoscopies. Cases included patients who collected the last rectal effluent and took photographs, while controls relied on verbal descriptions. Data collected included demographics, clinical information, bowel preparation quality, and lastly, stool clarity. A statistical analysis was performed to identify correlations and associations.

Of the 70 included patients, 45 were male. The mean age was 35.8 ± 14.3 years. Cases had a higher mean age (37.8 ± 14.6). A higher number of cases had comorbidities (11, 68.8%). Photographic recording of the last rectal effluent was not associated with the adequacy of bowel preparation. Thin yellow fluid was the most common last-rectal effluent clarity (33, 47.1%). Thin, clear fluid was significantly associated with adequate bowel preparation.

Objective assessment of last rectal effluent clarity correlates with the quality of bowel preparation. This can improve the quality of bowel preparation for colonoscopies and potentially reduce the need for repeat procedures, contributing to better patient outcomes and cost savings in healthcare systems.

The incidence of colorectal cancer (CRC) and preinvasive CRC (e.g., early colon cancer and advanced adenoma) is gradually increasing in several countries.

To evaluate the trend in incidence of CRC and preinvasive CRC according to the increase in the number of colonoscopies performed in Korea.

This retrospective cohort study enrolled Korean patients from 2002 to 2020 to evaluate the incidence of CRC and preinvasive CRC, and assess the numbers of diagnostic colonoscopies and colonoscopic polypectomies. Colonoscopy-related complications by age group were also determined.

The incidence of CRC showed a rapid increase, then decreased after 2012 in the 50-75 year-age group. During the study period, the rate of incidence of preinvasive CRC increased at a similar level in patients under 50 and 50-75 years of age. Since 2009, the increase has been rapid, showing a pattern similar to the increase in colonoscopies. The rate of colonoscopic polypectomy in patients aged under 50 was similar to the rate in patients over 75 years of age after 2007. The rate of complications after colonoscopy and related deaths within 3 mo was high for those over 75 years of age.

The diagnosis of preinvasive CRC increased with the increase in the number of colonoscopies performed. As the risk of colonoscopy-related hospitalization and death is high in the elderly, if early lesions at risk of developing CRC are diagnosed and treated under or at the age of 75, colonoscopy-related complications can be reduced for those aged 76 years or over.

Inflammatory bowel disease may cause long-standing inflammation and fibrosis and may increase the risk of adverse events in colonoscopy. We evaluated whether inflammatory bowel disease and other potential risk factors are associated with bleeding or perforation in a nationwide, population-based, Swedish study.

Data from 969 532 colonoscopies, including 164 012 [17%] on inflammatory bowel disease patients, between 2003 and 2019, were retrieved from the National Patient Registers. ICD-10 codes for bleeding [T810] and perforation [T812] within 30 days of the colonoscopy were recorded. Multivariable logistic regression was used to test if inflammatory bowel disease status, inpatient setting, time period, general anaesthesia, age, sex, endoscopic procedures, and antithrombotic treatment were associated with higher odds for bleeding and perforation.

Bleeding and perforation were reported in 0.19% and 0.11% of all colonoscopies, respectively. Bleeding [odds ratio 0.66, p <0.001] and perforation [odds ratio 0.79, p <0.033] were less likely in colonoscopies in individuals with inflammatory bowel disease status. Bleeding and perforation were more common in inpatient than in outpatient inflammatory bowel disease colonoscopies. The odds for bleeding but not perforation increased between 2003 to 2019. General anaesthesia was associated with double the odds for perforation.

Individuals with inflammatory bowel disease did not have more adverse events compared with individuals without inflammatory bowel disease status. However, the inpatient setting was associated with more adverse events, particularly in inflammatory bowel disease status. General anaesthesia was associated with a greater risk of perforation.

Endocytoscopy (EC) is a nuclei and micro-vessels visualization in real-time and can facilitate "optical biopsy" and "virtual histology" of colorectal lesions. This study aimed to investigate the significance of employing artificial intelligence (AI) in the field of endoscopy, specifically in diagnosing colorectal lesions. The research was conducted under the supervision of experienced professionals and trainees.

EMBASE, PubMed, Cochrane Library, Web of Science, Chinese National Knowledge Infrastructure (CNKI) database, and other potential databases were surveyed for articles related to the EC with AI published before September 2023. RevMan (5.40), Stata (14.0), and R software (4.1.0) were used for statistical assessment. Studies that measured the accuracy of EC using AI for colorectal lesions were included. Two authors independently assessed the selected studies and their extracted data. This included information such as the country, literature, total study population, study design, characteristics of the fundamental study and control groups, sensitivity, number of samples, assay methodology, specificity, true positives or negatives, and false positives or negatives. The diagnostic accuracy of EC by AI was determined by a bivariate random-effects model, avoiding a high heterogeneity effect. The ANOVA model was employed to determine the more effective approach.

A total of 223 studies were reviewed; 8 articles were selected that included 2984 patients (4241 lesions) for systematic review and meta-analysis. AI assessed 4069 lesions; experts diagnosed 3165 and 5014 by trainees. AI demonstrated high accuracy, sensitivity, and specificity levels in detecting colorectal lesions, with values of 0.93 (95% CI: 0.90, 0.95) and 0.94 (95% CI: 0.73, 0.99). Expert diagnosis was 0.90 (95% CI: 0.85, 0.94), 0.87 (95% CI: 0.78, 0.93), and trainee diagnosis was 0.74 (95% CI: 0.67, 0.79), 0.72 (95% CI: 0.62, 0.80). With the EC by AI, the AUC from SROC was 0.95 (95% CI: 0.93, 0.97), therefore classified as excellent category, expert showed 0.95 (95% CI: 0.93, 0.97), and the trainee had 0.79 (95% CI: 0.75, 0.82). The superior index from the ANOVA model was 4.00 (1.15,5.00), 2.00 (1.15,5.00), and 0.20 (0.20,0.20), respectively. The examiners conducted meta-regression and subgroup analyses to evaluate the presence of heterogeneity. The findings of these investigations suggest that the utilization of NBI technology was correlated with variability in sensitivity and specificity. There was a lack of solid evidence indicating the presence of publishing bias.

The present findings indicate that using AI in EC can potentially enhance the efficiency of diagnosing colorectal abnormalities. As a valuable instrument, it can enhance prognostic outcomes in ordinary EC procedures, exhibiting superior diagnostic accuracy compared to trainee-level endoscopists and demonstrating comparability to expert endoscopists. The research is subject to certain constraints, namely a limited number of clinical investigations and variations in the methodologies used for identification. Consequently, it is imperative to conduct comprehensive and extensive research to enhance the precision of diagnostic procedures.