I'll be speaking about detection and then sort of diagnosis, and I love that we position this now after Amit described sort of how we get to the CECM, because that's really key in our detection as well, is that we aren't so fatigued after our insertion, we can spend our energy and time looking. So detection in colonoscopy, how to maximize it, how to measure it. If we are doing colonoscopy for colon cancer screening, we really should be measuring our quality, measuring our detection rates. It is recommended that physicians who perform these measure quality, including the adenoma detection rate. And so this is definitely in our purview and something that we should have as a priority as endoscopists. We know this, but just so we have the common language of when we're talking about detection, many times we're talking about adenoma detection for these measuring of quality, adenoma detection rate. It's been strongly associated with colorectal cancer incidents and death after colonoscopy with this 3% association and reductions in interval cancer and 5% associated reductions in cancer death after colonoscopy, the higher your ADR for each 1% increase in that ADR. So ADR has clearly been shown as a great surrogate marker for detection and for quality. The targeted minimum ADR currently is 25%. That's about 30% men and 20% for women. This likely will increase as more and more studies have been done showing much higher ADRs across different cohorts and populations and settings, that ADR is much higher than these numbers. And so I would, everyone anticipate that these benchmark thresholds will be higher in the near future. So the one thing about ADR as well is it had been suggested to be for screening patients that screening age initially 15, now we're at the 45, but there have been also many studies that have shown that ADR overall is reflective of quality. And it doesn't differ too much from an endoscopist performance. I mean, I don't think we change our behavior if we're screening a patient as opposed to if we're doing a surveillance, for example, our goal is still detection and looking. And so this is a study that we did at two different centers and then some modeling to show we don't need to just stratify our ADR to screening because our overall ADR is similar to that. I think one of the barriers to measurement of our detection, for example, has been, well, we need to cipher out the indication. Many patients may come in for screening, but they may also have bleeding, what category do you put them in? How do we go back and find that just becomes a barrier. So I think showing that comparable ADRs is really important because we can move the field forward to simplify the measurement of it and the reporting back. The good news about ADR or the bad news about ADR, I'll say first, is that it's highly variable. So this metric that's showing adenoma detection rate really shouldn't vary across endoscopists because overall we have, in general, mixed populations of patients. So I think that showing even in the Corley study, now almost a decade ago, this range between seven and over 50% is quite striking to show differences in detection. We had similar ranges when we look nationally at VA providers and you can see, again, this bell curve and there should not be a bell curve or a range for detection. This is really something that should be all on the right side of that curve. So we can talk in this session about many different techniques and technologies and people who can try to, factors who can try to change detection, but it really is us as endoscopists who have the most power in terms of detection. This has been encouraging that when we've looked at when individuals are trained and have higher awareness of detection and then increase their detection rates, then reductions interval cancer follow. So we can change and we can improve and protect our patients more. So how can we do high quality inspection, high quality detection? We really do need to approach this with that mindset about what are we looking for? We're not looking for cancers. I always say that our privilege in colonoscopy is we can find stage zero, right? We can find it before it's cancer. We want to look for the subtle things, the flat and the depressed and remove them. And if that's our mind when we start the detection, and then we have the tools of that, which will go through some of how to recognize, then that's really huge in the starting game for detection. And then the technique part. So Amit talked a lot about insertion and having a straight scope when we get to the cecum. That's so important. If we aren't stable while we're withdrawing, that makes it so challenging for us to look behind folds, to be stable, to be efficient. And so that's key. Having a clean mucosa, looking behind those folds, being dynamic in expansion and collapsing. It's really important. I find that with the world of water insertion, a lot of the trainees are hesitant to expand the colon then on withdrawal. And I think that's just something that's really important that we do need to have different tensions in the colon wall to identify lesions. And we definitely want to take time, but we want to be efficient with our time. And I think a longer, longer withdrawal is not necessarily a better withdrawal. There's a sweet spot, I'm sure, that we'll all find. Too short's not good, but too long is also very inefficient. So we want to take time. And the time we take, we want to take most of it in that right colon, examining it twice, either in retroflection or examining it twice in forward view. And then the different tools, optimizing things that are already available to us that aren't necessarily advanced, like the lighting on the processor, the monitor itself, using a cap. Those are all things that we have available, tools that can help us with detection. And then certainly engaging in a quality insurance program is a great tool because when we're accountable, then we perform better. When we have a community that's accountable, then we can discuss and improve together better. So I won't go a lot into Bell Prep, but certainly it's the cornerstone of detection because we have to have a clean colon. We luckily have the ability with the water jet to wash, but that leads again to our time being spent washing and suctioning, taking our cognitive time away from looking. And that's just, again, anything the patient and the unit can do to get the patient clean before the procedure is certainly going to be a much better system. You can see here, yes, this colon, we can wash and get it clean, but that's time taken away from looking. And certainly these subtle lesions like this could be under a stool. So getting to here is definitely feasible, this excellent quality, and you can just see the difference already. I can see very clearly the vessels, the folds, the lines of the colon, all of the things I'm looking at to find polyps, I can see much more clearly with an excellent prep. The split bell dose preparation has been around for 10 years now. That should be standard for our units. A low residue diet has also been recommended, and I think that the results show superiority in incorporating that into our units. There's better patient adherence then. So I think that making sure our units follow the systems of Bell Prep protocols are really, really important in the detection realm. And then, again, I'm not going to go in as much with the insertion, but just highlighting and emphasizing having a straight endoscope is so important in our detection. So we need to have awareness of loops, awareness of the equipment that we are using, how we're handling it, and then, of course, the patient, because a straight scope is responsive, we have that control, we're more efficient, the patient's more comfortable, and then we can focus on that inspection. So let's get to that part with detection. Here, again, when the colon looks like this, we can look at the vessels. We can suction through clear liquid quickly. We can look at the folds and do this sort of circumferential spiral withdrawal where our eyes are surveying in order to detect polyps. So this is the goal of colonoscopy, that we can see these parts of the colon lining. Because when we are doing inspection, we're looking for certain patterns. We need the clean mucosa. We need that their lighting is good. I have the chromoendoscopy here mainly to show you that that small lesion that we found with white light is certainly very subtle and can be highlighted with that chromoendoscopy there. So back to the mindset. When we are inspecting, we want to basically and certainly look for these polyploid type lesions, but really look for the flat ones. Because if you find the flat ones, you're going to certainly find the more obvious. So prime your mind that we're searching for these subtle lesions. There could be a subtle color differential. We're looking at the lines, the vessels, and the folds are sort of the three things. So when we look at this image, for example, our eyes are following around. You're seeing the folds. This is to collapse. So I would expand the colon more. But as we follow the folds, you see an irregularity of the fold there, which could be a lesion. So those folds, the vessels here aren't as prominent. We look at the innominate grooves, which are the lines of the colon. And sometimes they're more helpful. So let's go through a few examples. Here, the vessels are very prominent. Right now, my eyes are following the folds. They're following the folds. I'm seeing that right there at the, are you able to see my cursor? Right here. Yes. Okay, great. Okay. So right here, you can see that this fold is very smooth. And then my eyes go to this fold, and that's not. So then we would get closer and inspect that further. So again, smooth fold, continuous vessels. We have here a disruption of the fold, and we have a disruption of the vessels. Here's another example. Again, what are the signatures of serrated lesions? Well, those are often that mucus cap that we look for. But another key thing in terms of the detection is if there's a disruption of the vascularity of the colon, right? So you can see here, our eyes immediately go to the appendiceal orifice. Then we start to follow out. We're looking at the vessels. Well, why is there a complete disruption of the vessels here? My eyes were following this. My eyes are following this. And then there's a disruption. So those are, again, just key detection strategies to use so that we can find polyps. Here are the other features of the serrated lesions. The mucus cap, again, is something that we should not dismiss as stool or debris, but that could be an actual lesion. These lesions often have indistinct borders, have these irregular shape, have the O signs or the pits. And you can see some examples here, really subtle. But in this particular case, you can see a slight elevation. There's a disruption of the lines. You can see that cloud-like surface here. The dilated O pits are more striking to draw your attention. So let's use some of these strategies while we watch this video. So we're following the folds, right? And we're following the color. And in that particular case, let me start it again. So this fold becomes a little bit different, right? It's not continuous. There was more erythema there. I would at least then pause and look at that further. So that's a flat lesion there that you can see crosses several folds. So using the strategies that we said, looking at the folds, looking at the lines, looking at the vascularity and the color can help us be quick detectors of those. So let me go through a few more here with the group. Try to do this practice with me as we're looking at the folds and coming along here. You can see in this particular area, disruption of the vascularity and then a thickening of this fold. So again, drawing our eyes to that area, you can see this is a flat lesion there. Here's another example doing that same exercise. We're following the lines. We're following the folds. Here, the vascularity is not as prominent, so I'm not using that as much. I'm not seeing particularly anything. I may wash this debris here, but again, the feedback is now normal, so I can be efficient and move on. The vascularity here is very prominent, so I'm going to be surveying that. It all looks very uniform. The folds look very smooth. I'm moving on. Here, the lines are very prominent. I'm using these innominate grooves, these lines of the colon. I'm using that as the tool to help me quickly look for lesions. If there's a disruption in that line, then I would pause and look for a lesion. Here, we have the cecum with the appendix in the distance. There's definitely some mucus and stool, but what's quickly in everyone's alarm is that there's this mucus cap right between 3 and 8 o'clock. Then I think the point here is, see these lines? The lines stop. You have the mucus cap with the glare. You can see the lacy vessels. Then you want to make sure that it doesn't stop there because they have these indistinct borders. This particular lesion, you can see, keeps going. We would inspect that further. Here's another example where, again, I'm using the vessels initially. I'm following the folds. Then in this particular fold, you can see there's more redness. There's more thickening. That's certainly something I would inspect further. In this one, lines are very prominent. I'm following the lines. Then you can see the line is disrupted here. There's a slight elevation. I would inspect that further. So I just went through these examples to reiterate again and again, if we use that approach for detection, that really, as the endoscopist, will empower you to be efficient in your inspection. You have these mind maps of what we're looking for and can have good confidence in your inspection as well. I think this may be one of the latter ones that I'll share in terms of looking. So in this particular case, a lot of our eyes go here to this sort of collapsed area. But what's also striking, if we start to inflate that, this area, I'm actually looking at the folds. So if you follow this fold around, there really shouldn't be this sort of bite out of a fold. So that's a deformity of a fold. And your eye, again, is looking for uniformity, continuity, continuous vessels, lines, folds. So our eyes should draw right there and look at that further. And you can see, again, that's a fixed defect in a wall that really could only be caused by a lesion or a cancer. So something, again, to prime you with. And then in this one, similarly, this is, again, too collapsed, right? So we'd want to inflate this and expand it. But even in so, you can see here, this starts to be less sort of pliable and more fixed in this area. And why is that? Why did the fold become disrupted there? And there's a large lesion. And this shows the vascularity. So sometimes dye can help us certainly accentuate. It can help us train our eyes and mind as well a little bit when we are becoming better detectors. It can help us appreciate the lines and give us imprints of what those lines look like later without dye. And you can see here, this superficial elevated, this flat, and then this thickened fold that was a depressed lesion. In white light, you're able to appreciate them. And certainly, they're highlighted better with the dye. This is another example of that. So again, I'm following the folds. I'm following the lines. There's friability. There's erythema there. We can all clearly see that flat lesion. You can see now it will be more red with dye because the dye goes into the lines and the lesion doesn't have the lines. That's why it's the red and blue. You can see there that lesion in that particular case. Let's just go to that spot now that you've seen it. But try to look at this area now before the dye is sprayed. So we're going to come back. This one was easier to see in white light. Now see this one. See the disruption of the vessels and the slight erythema? That should get you there with white light. But now that you've seen the lesion with the blue dye, kind of make that imprint for yourself. And here's just another example where the dye just highlights those lines so well. Everyone's colon. So use those for your detection skills. Look at those lines and see when they're disrupted that there's likely a lesion there. The use of caps. So caps can be very useful in detection. They stabilize your scope a certain distance from the mucosa as you're inspecting. They help you peer around folds, though you still need your technique of twerking and dialing to look behind them. The idea here, though, is it does help you retract. There are certainly many studies and randomized studies and meta-analyses of randomized studies to show the benefit of cap, particularly in low-level detectors and how it can increase the yield of adenoma detection rates as well as the efficiency of the exam. So things to consider about using a cap. We standardly use a cap in every colonoscopy in my practice. And this just shows, again, this particular one is the Endocup. So I think Doug had alluded to the Endocup use. The Endocup use, this is an earlier version. So you don't see the phalanges so much now, but this just, I like this to give the concept to show what is actually happening. It's pulling those folds back behind you as you withdraw. So again, lots of studies to show the benefit of CAP use during colonoscopy for adenoma detection, particularly in lower performing detectors. And I want to highlight that the ability for us to find polyps is not innate. It's not, it's not something that is natural. And we, as we become an endoscopist, it's an automatic cognitive and skill that we have. So this is a study we did years ago to show even in a center that was very interested in adenoma detection and finding flat polyps, it took quite a long time to get to the rate of finding them in close to 1500 procedures in finding, getting to certain rates of polyp detection. We also did a nested case control study to show when we train in detection, we can get higher yields of adenoma detection rates. So having this awareness, having that mindset, and then having some of the tools and techniques can indeed increase your adenoma detection rate. And so if it's not innate, can we use, in addition to training ourselves and self-study, can we use artificial intelligence, for example, to help? Certainly has been shown to increase adenoma detection rates in most trials, particularly again in low level performers. This, Doug provided me this video just as an example to show, you can see here the box will light up when a polyp is identified. It stays on the screen unless you turn the toggle it off or pause it, but it'll stay there as the polyp is there, even during your removal process. This is in the detection mode. And then there are features in some that also give you information about the polyp diagnosis. So AI is certainly deployed in many units across the United States now. We deployed it across the VA actually to 70, close to 80 sites now, 80 facilities within the VA have AI systems and it's showing some benefit in the use of that. And then lastly, what can we do about quality and measuring it? Certainly engaging in quality improvement programs is beneficial. This has been shown and published on and implemented over the last decade to show we all should be engaged in quality improvement programs, whether that is through measurement and reporting, whether that's through leadership training or through communities of practice. This definitely is something we should all be involved in and pursue. We showed that getting individual assessments through video-based assessments of your actual inspection also improved your ADR. So as a unit, if you are able to measure and report back quality and you identify low performers, well, engaging not only in the report card, but when you get the report card, if there are sort of actionable items with video instructions of areas for you to improve on, that can show benefit as well. This particular one was on colonoscopy quality inspection. So you can see here, the colonoscopy inspection score involves fold examination, cleaning and distention. So having videos that then show these specific steps within inspection and then trying to, and then giving advice as to how you could improve them and then trying to implement that advice led to improvements in ADR in the lower performing group. We have a VA endoscopy quality improvement program, which is a program we initiated where we have national dashboards to all sites across the VAs, which is about 120 sites. And so we deliver their ADR, CEQA intubation and bowel preparation quality to sites. And then we have monthly virtual sessions that we focus on active learning, where we do exercises to find polyps or insertion technique or bowel preparation to improve quality. This was part of a randomized study that we hope to publish the results of soon, but the program continues because it showed benefit. And so this is again, just emphasizing that quality assurance program engagement is really important. And if you're in private practice or solo certainly societies such as ASGE or being able to submit to GI quick is really important to be able to measure and get that feedback. This is an example of our earlier dashboard. We've now migrated to a little more interactive one, but just again, showing the importance of seeing your data is powerful and motivating, having you accountable, showing your performance against your peers, as well as national benchmarks and society thresholds is motivating. So definitely quality metrics are recommended to be measured and reported. Detection is a huge one of these quality metrics. It's probably one of the main driving ones because of its direct correlation to colorectal cancer incidence and mortality, which is why the bulk of us are doing colonoscopy for colon cancer prevention. So we need to be our highest in that exercise. It's continues to show significant variability across endoscopists. So this area to improve our detection is certainly there and we can each motivate ourselves and then our groups to do that. And finding polyps is difficult. I don't think we should think that this is an easy task. It will take effort, but it's achievable with that effort. And having audit and feedback is a key component. And I'll stop there for this session. Thanks, Doug. Thank you, Tanya. That was fabulous. So we've got a lot of questions. I want to start with, I think we need to deal with simethicone. Okay. Can you talk about simethicone in the PrEP and how you use it during the procedure? Great. So simethicone definitely has been a big issue because we had used a lot of simethicone in the past. I think having the ability to see is so important and washing bubbles in air will only create more. So we need simethicone. At UCSF, we have that as part of the bowel preparation and it still is not enough. And UCSF at first, when Olympus came out and put the statement about the simethicone, they actually banned it initially because infectious control banned the use of it. But with a lot of education to them, allow us small doses of it through a syringe through the accessory channel. And so in every colonoscopy that I do, they have a syringe prepared essentially that I, and a bottle of water with simethicone that we use that I use for the procedure. I typically am spraying most of it in the cecum once I'm at the cecum and then I use my water jet. And there are other times I may need it once I get to the left colon, but I find the bulk of my use of it is in the right colon. And I certainly think it's in a vital part to colonoscopy. Yeah. So I agree with that. There's actually some evidence that simethicone improves the adenoma detection rate when you include it in the prep, you've got to put enough in the prep. The patients should be ingesting in divided doses with a split dose, something in the range of seven or 800 milligrams of simethicone. And one other thing that I do is when I enter a bubbly colon, I start flooding that colon during insertion because when you're coming out, you often have to direct the spray at the bubbles. And I think you should wash down all of the bubbles before you move on. But it's easier when you put it in during insertion, it kind of sloshes around and during withdrawal, a lot of times, a lot of that, that stuff is, is cleaned up. But yeah, the companies say that we're not supposed to put it in the, in the water jet. No water jet. Yeah. Well, that is extremely problematic. And I think, you know, the, one of the issues about it is that, you know, for colonoscopy, we don't really have evidence that we have problems with, with infections transmitted by the scopes. So I think it's, it's problematic, but it's important. Could you guys say, talk a little bit about your second right colon examination? Do you, how do you decide whether to do it in retroflexion or forward view? Do you have any tips about getting into retroflexion in the cecum? I typically, if I, I try to retroflex in every patient. I think the newer scopes with the passive bending allow that more easily. I would say there's some colons still that aren't so easy to retroflex in. And in those I still may try, cause I think it expands it a little bit. And then, and then I look, so I would say my approach is I do try in every patient and then, and then I'll use that as my first look. And then I will then go and do the second look with the forward view as I'm withdrawing. Amit, any preferences? No. So I don't retroflex routinely. If I'm, I usually look at it twice forward view. And if I feel that the folds are very prominent and I'm not getting a good view, I use a cap in every case. So if only I've got a sense that I've not been able to see certain areas of the folds, especially the proximal aspects, only then I'll retroflex, but not routinely, but definitely if there's a large polyp and if it is going to help me to, to inject the proximal side or examine the entirety of the polyp, that is where I usually do retroflex. So I think your point is, your point is that last point is a good one because retroflexion is a technique that is, that is an important part of the armamentarium of large polyp resection. I generally consider that retroflexion with a standard scope. And I guess a pediatric colonoscope is a safe maneuver in the right colon, most transverse colons and in the rectum. If you're retroflexing in the sigmoid or the descending, which is occasionally helpful for a polyp that's draped over a very sharp bend, I think you should switch to an upper scope to do under those circumstances, but otherwise retroflexion is safe. I, I always double examine the right colon always now. And, um, I tend to do the second examination in retroflexion, but what I do is I size up the right colon, uh, from a distance. If you're sitting back in the distal ascending colon, and you can clearly see the ileocecal valve ahead of you, it's going to be a relatively straight, straightforward retroflexion, as long as the right colon is not too, uh, narrow. And I think if you haven't done it much, uh, you should learn how to do it because of the, the skill gain. I think it's a little trickier with a cap on the scope than it is with a cuff because that cap sticks out a little bit and it's just a little bit harder to, uh, make the turn. You get a little bit more scraping of the mucosa, but I think the key things are get, get down in an area that you see is, has got enough capacity to allow that turn to be made and then, uh, get in the up direction. And then I usually push on the insertion tube a little bit because it makes that scope tip start to turn back under the valve and then go max left. You know, it's one thing that's critical as an endoscopist is to start to be able to think not only in terms of what's on the television screen, but I say, think like the scope. Understand and think about what the shape of the scope is. And if you get the scope out on the examining table and you play with it, um, it, what it does on the table is exactly what it does when it's inside the patient. So when you're max up in a standard colonoscope, all three of the companies, they go 180 degrees. When you go max up and max right or left, they do not turn in the right or left direction. They hairpin back on themselves. And so you start to see the insertion tube better when you're max up and max left. So I usually go max up, push in a little bit and then go max left and then rotate the scope in the counterclockwise. Yeah. That usually will flip you into that retroflex view. Then when you come back, you're coming back in retroflexion all the way to the hepatic flexure. Then you release the controls and pull down on the insertion tube so that you don't unwind too hard against the wall. That's the problem with retroflexion with a colonoscope in the sigmoid or the descending. It's not so much that you can't get into retroflexion. The question is, can you safely get out of retroflexion without putting too much pressure, uh, on the wall? But if the right colon is, is got a big bend in it, you know, like you're, you're sitting back in the hepatic flexure and you can't see the cecum because the cecum is flipped back up in the abdomen. You're going to have, uh, potentially more trouble in retroflexion. And the most important thing I think Tanya brought out was examined the right colon, uh, twice because we miss relatively more often. You can miss anywhere, but we miss more often. Now, Tanya, um, we've got, I think there are two basic problems with, that we can encounter with detection. One is we fail to expose the mucosa. And I think you said you like to have a cap. I like a cuff. Amit, do you use anything routinely? Cap. Cap. Okay. There is, there is clear data from randomized controlled trials for the cuff and the cap. Um, and those are mucosal exposure, uh, devices. We're also going to see artificial intelligence programs that, that evaluate how carefully you're doing the examination in real time. And we'll suggest to you that you need to go back in and look behind a fold. We don't have those commercially available. Then we have highlighting devices. So Tanya, if I were to ask you, what is the most effective highlighting device and your choices are AI, electronic chromoendoscopy, whether it's, um, MBI in the Olympus system, or it could be LCI in the Fuji system. It could be the eye scan in the Pentax system, um, or chromoendoscopy. What are you, what are you going to rely on, or what do you think the average, uh, endoscopist is going to rely on in the future? I think the average endoscopist will rely on AI. Okay. Um, I, I pers, I will say personally right now, the AI literature, if you look at it, the randomized controlled trials are very good. And what we're seeing are these pragmatic studies on randomized trials that are not getting as good a results or negative results. One of them, actually, the ADR was lower with AI than it was without AI. What's the explanation for, for these mixed results? I tell you, I I've got AI and I find it underwhelming in, in, in regular practice. And I, you know, if, if I have my choice between a cuff and, and the AI device, I take the cuff. Oh, for sure. Yes. I mean, but you didn't ask me about a cap. You asked me about AI or chromo or NBI. I that's why I said on average, I think, I think we have the tools now with a cap and white light and using the washing it and knowing the patterns to look for, to find these polyps. I really think that we, it doesn't have to be fancier than that. And I think that's, I mean, I think it's important to, to think about that because both of them have a cost, right? The cap or the cuff, they have a cost 25 bucks, you know, about AI has got a cost. So, you know, a lot of people are reluctant to use these things out in the community and ambulatory surgery centers because it cuts into their, to their to their profits. So I sort of agree. I like the mucosal exposure device. I find it more valuable than a highlighting device, but truth is I kind of like both. Well, what do you think about why, why the evidence is mixed and why we're seeing these pragmatic studies with AI that are not showing a benefit? Yeah. I mean, I think some, some is if you've used the AI, which you have, I mean, it, it, it highlights a lot of things, right? So there's a lot, there's not the sensitivity can be high. The specificity is not. And so you start to become a little bit desensitized to it. So it may, it may alert you to look at an area, but then you still need to use your discretion about was that noise or do I look there further? And so I feel like for that, there may be some turning off of the information over time of how you use it perhaps. Definitely think you're right. I think that can happen. Yeah. So that may be. And then I'm not, I'm not sure the other reasons. I mean, I think the studies, even the randomized trials have been mainly higher for the low level performers, right? I think that that I'm curious if it helps. I mean, I think an interesting thing would be if you, if, if it can help train or if it hurts you to find them, right. Do you, does it, does by using that, does it actually inform you? And if you took it away, then you find them more in the future or, or does it actually, you become dependent on it? I don't know the answer to that. Yeah, it's a good question. I don't think we know. I mean, yeah, I always worry about it. Like, should we be training fellows and trainees with AI to begin with? I think, I mean, that almost makes me feel that it gives them, will give them a false sense of security that, okay, I turned the AI on and I'll just look at the area that the AI highlights. Right. I mean, I think the learning process has to be without AI and, and, and AI should be just a supplement at the end. I don't know. Is this, I mean, I, I often say to people that, you know, we, we know that detection is, is highly variable. I think the benefits of devices are also highly variable in the end to understand whether you're going to benefit from AI or a specific device. You may have to trial it yourself. And, and one thing I like about Endocuff, cause I, I'm very tuned into time. I can withdraw a couple of minutes faster with Endocuff and detect as much or more because the main work, and we, and we have to remember that, that the highest level detectors in white light with nothing beat lots of people in these in these detection studies that are level detectors. They're, they're not using anything except their technique, but that technique, the work of it is going in repeatedly, compulsively, systematically, and looking at the proximal sides of folds. Well, if you've got a cap or a cuff on the, on the end of the scope, you can do all that faster. And so I think that that's a particular advantage. Yeah. And I think if AI with the part that's not available yet, but if it shows us what we've seen, I think that would increase that efficiency too, perhaps, because then you're not going back and wondering, I mean, I think if you have a system now it works, but I find many of us go and like, did I look at that area? Did I get that fold? So I think if AI kind of gave us, you've seen this move on, that would also give confidence to move on and, and, and give you a more clarity of what's been examined.

colonoscopy

adenoma detection rate

colorectal cancer

endoscopists

quality improvement

AI detection

mucosal exposure

screening procedures