Mean polyp per patient is an accurate and readily obtainable surrogate for adenoma detection rate: results from an opportunistic screening colonoscopy program

The incidence of colorectal cancer is rising in several developing countries. In the absence of integrated endoscopy and pathology databases, adenoma detection rate [ADR], as a validated quality indicator of screening colonoscopy, is generally difficult to obtain in practice. We aimed to measure the correlation of polyp-related indicators with ADR in order to identify the most accurate surrogate [s] of ADR in routine practice. We retrospectively reviewed the endoscopic and histopathological findings of patients who underwent colonoscopy at a tertiary gastrointestinal clinic. The overall ADR and advanced-ADR were calculated using patient-level data. The Pearson's correlation coefficient [r] was applied to measure the strength of the correlation between the quality metrics obtained by endoscopists. A total of 713 asymptomatic adults aged 50 and older who underwent their first-time screening colonoscopy were included in this study. The ADR and advanced-ADR were 33.00% [95% CI: 29.52-36.54] and 13.18% [95% CI: 10.79-15.90], respectively. We observed good correlations between polyp detection rate [PDR] and ADR [r=0.93], and mean number of polyp per patient [MPP] and ADR [r=0.88] throughout the colon. There was a positive, yet insignificant correlation between advanced ADRs and non-advanced ADRs [r=0.42,p=0.35]. MPP is strongly correlated with ADR, and can be considered as a reliable and readily obtainable proxy for ADR in opportunistic screening colonoscopy programs

Characteristics of colorectal polyps and cancer; a retrospective review of colonoscopy data in Iran

Early diagnosis and endoscopic resection of adenomatous polyps is the main approach for screening and prevention of colorectal cancer [CRC]. We aimed to assess polyp detection rate [PDR] and to characterize demographic, clinical, and pathological features of colorectal polyps in an Iranian population. We retrospectively analyzed the data from 5427 colonoscopies performed during 2007-2012 at Masoud Clinic, the main endoscopy center associated with Sasan Alborz Biomedical Research Center, in Tehran, Iran. Our sample included 2928 [54%] women and 2499 [46%] men, with the mean age of 48.3 years [SD=16.1]. The most common reasons for colonoscopy included screening in 25.0%, and gastrointestinal bleeding in 15.2%. Cecal intubation was successful in 86% of patients. The quality of bowel preparation was fair to excellent in 78.1% [n=4235] of colonoscopies. Overall PDR was 42.0% [95% CI: 40.6-43.3]. The PDR in men [51.1%, 95% CI: 49.1-53.1] was significantly higher than women [34.2%, 95% CI: 32.4-35.9, p<0.001]. Polyps were more frequently observed in patients after the 6th decade of life [F=3.2; p=0.004]. CRC was detected in 2.9% [73/2499] of men and 1.9% [57/2928] of women [p=0.02]. The mean age for patients with cancer was significantly higher than that for individuals with polyps, 60.9 [SD=13.4] year vs. 56.9 [SD=13.7] year, respectively [p=0.001]. Almost 82.8% of the lesions were precancerous with tubular type predominance [62.3%] followed by tubulo-villous [10.3%], villous [6.6%], and serrated [3.6%]. Hyperplastic/inflammatory polyps comprised 17.2% of lesions. Distal colon was more prone to develop polyps and cancer than proximal colon in our series. These findings provide a great infrastructure for next preventive programs and have implications for colorectal cancer screening at population-level

Oral nitrate reductase activity is not associated with development of non-alcoholic fatty liver disease [NAFLD] and non-alcoholic steatohepatitis [NASH]: a pilot study

NAFLD/NASH is a manifestation of metabolic syndrome and is associated with obesity/overweight. Not all obese/overweight individuals develop NASH. Gastro-esophageal reflux disease [GERD] is considered a gastrointestinal manifestation of the metabolic syndrome and is associated with obesity/ overweight. Again not all obese/overweight individuals develop GERD. Recent data show association of dietary nitrate content and oral nitrate reductase activity [NRA] with GERD. Nitrates need to be converted to nitrite [done in human beings by nitrate reductase of oral bacteria exclusively] to be active in metabolic pathways. To assess the relation between NASH/NAFLD and oral NRA. Oral NRA was measured in individuals with NASH [compatible abdominal ultrasound and two elevated ALT/AST levels over six months] and was compared with that of those without NASH. Oral NRA was measured according to a previously reported protocol. Eleven NASH patients and twelve controls were enrolled. Mean oral NRA activity were 2.82 vs. 3.51 microg nitrite-N formed per person per minute for cases and controls respectively [p=0.46]. According to our data, oral nitrite production is not different between individuals with and without NASH.

Cysclosporine-A versus prednisolone for induction of remission in auto-immune hepatitis: interim analysis report of a randomized controlled trial

Corticosteroids are used to induce remission in auto-immune hepatitis. They are not universally effective; therefore, alternative treatments are needed. In this study Cysclosporine-A has been compared with prednisolone as an alternative treatment in a randomized controlled trial. This paper is an interim analysis of an ongoing clinical trial. Sixteen years and older consenting patients were enrolled. Group-A received prednisolone and group-B cyclosporine-A according to a preset protocol and followed at regular intervals for 48 weeks. Final assessment was done at week 48. Primary outcome was response rate as defined below. [Complete response] was defined as achieving AST and ALT in the normal range and absence of any clinical signs of deterioration, and partial response was defined as a decrease in AST and ALT by less than half of their original values but not to within normal limit. Non-responding ones at week eight were switched to the other arm. Thirty-nine patients were enrolled [24 group-A, 9 male]. Mean AST and ALT at baseline were higher in group-B, but other variables were comparable. At week 12, 34.8% and 64.3% of group-A and B had achieved AST and ALT in the normal range less than 40 IU/L]respectively [P=0.081]. Corresponding figures at week 48 were 50.0% and 47.6% 0=0.62 and48 respectively]. At week 12, 86.9% and 85.7% of patients had AST and ALT levels less than twice upper normal limit in groups-A and B respectively [p=0.54 and 0.42]. Corresponding figures at week 48 were 90.0% for both groups. There was one treatment failure in group-B which did not respond to prednisolone either. Serious adverse events [death and liver transplantation] occurred in group-A only. Serum creatinine did not change during the study period in either group. According to our data, Cyclosporine-A is as effective as prednisolone for induction of remission in AIH. Adverse event and serious adverse were more common with prednisolone

Serum cystatin-C is not superior to serum creatinine in predicting glomerular filtration rate in cirrhotic patients

Assessment of glomerular filtration rate [GFR] by common creatinine-based methods is potentially inaccurate in patients with cirrhosis. Cirrhotic patients have several underlying conditions that contribute to falsely low serum creatinine concentrations, even in the presence of moderate to severe renal impairment. Therefore creatinine-based methods usually overestimate true GFR in these patients. Cystatin-C is a low molecular weight protein and an endogenous marker of GFR. We compared the accuracy of plasma cystatin-C and creatinine in assessing renal function in cirrhotic patients. We serially enrolled cirrhotic patients with stable renal function admitted in our ward if they met the inclusion criteria and consented to participate. Child-Pugh [CP] score was calculated for all patients. GFR was calculated using serum creatinine, serum cystatin-C, and 99m TC-DTPA clearance with the last one serving as the gold standard. The area under curve [AUC] on receiver-operating characteristic curves [ROC] were used to assess the diagnostic accuracy of each calculated GFR with that measured by DTPA. Fourty-eight patients were enrolled [32 males, 66.7%]. Nine were in class-A, 20 in class-B and 19 in class-C of CP. Cystatin-C did not perform well in predicting the true GFR, while serum creatinine performed relatively accurately at GFR<80ml/min [AUC=0.764, p=0.004]. Serum creatinine at a cutoff of 1.4 mg/ dl was 20% sensitive and 92% specific and with at a cutoff of 0.9 mg/dl was 77% sensitive and 72% specific for diagnosis of impaired renal function. Cystatin-C could not predict GFR effectively even after stratification for CP score, gender, and BMI. Serum creatinine could predict GFR<65ml/min in females [ROC curve AUC=0.844,p=0.045]. In those with BMI>20 kg/m2 a GFR<80 ml/min could also be predicted by serum creatinine [ROC curve AUC=0.739,p=0.034]. It also could predict GFR<80ml/min in patients with CP class A and B [ROC curve AUC=0.795,/7=0.01], but not in patients with CP class C. Neither serum creatinine nor Cystatin-C are good predictors of GFR in cirrhotic patients, although serum creatinine seems to perform better in selected subgroups

Inflammatory bowel disease

Inflammatory bowel disease [IBD] is the term used for a group of diseases with yet unknown etiology, prevalence of which is increasing almost everywhere in the world. The disease was almost non-existent four decades ago in the east, including the middle-east, while now a days it is seen more and more. In addition to the increasing prevalence, our knowledge about its pathogenesis, clinical course, diagnosis, and treatment has changed dramatically over the past couple of decades. This has changed our concept of this group of diseases, their diagnosis, treatment, and treatment goals. Considering the vast literature on the subject, it is timely to review major topics in IBD with a look on the regional progress and knowledge as well. This essay is aimed to cover this task

Treatment of gastro-esophageal reflux disease may improve surgical outcomes for chronic otitis media

This study has been designed to investigate the clinical association between gastro esophageal reflux disease [GERD] and chronic otitis media [COM] in adults and also the role of GERD treatment on the outcome of COM surgery. In a randomized clinical trial, 58 patients with COM who were candidates for surgery were evaluated for GERD and divided in two groups; GERD positive [case] and GERD negative [control] patients. The GERD positive patients were randomized to either receiving medical treatment for GERD or not prior to surgery. The surgical outcomes were assessed at 3 and 6 months after COM surgery in the three groups. Fifty-eight [26 males] patients were enrolled. Forty-two [72.4%] of these had GERD according to a validated questionnaire. Three months after surgery auditory recovery in GERD negative patients was significantly higher [16[100%]] than those suffering from GERD [28 out of 42 [66.7%]], p=0.008. The figures remained similar at six months follow up as well [100% vs. 72.5% in GERD negative and positive patients respectively, p=0.002]. In the GERD-positive group, 8 of 18 [44.4%] patients who did not receive GERD treatment before tympanomastoidectomy recovered after three months whereas, while 20 of 24 [83.3%] patients who received GERD treatment recovered during this time [p<0.001]. At six months 44.4% of non-treated GERD patients had auditory recovery as compared to 95.5% of those treated for GERD [p<0.01]. Our data show that the effect of GERD on the outcome of COM surgery may be considerable. On the other hand, treating COM patients for GERD medically for two months before tympanoplasty improves the surgical outcomes. Therefore, we suggest that COM patients be evaluated for GERD before undergoing tympanoplasty and if GERD is present, they be treated medically for a couple of months before undergoing surgery.

Impact of quality mentorship on achievements of shiraz medical school in the 1970s and the role of Professor Faramarz Ismail-Beigi

Almost four decades ago, an eminent physician, outstanding mentor and scholar, Professor Faramarz Ismail-Beigi [b. 1941] was appointed Chair of the Department of Internal Medicine at Shiraz Medical School. Soon, this proved to be the beginning of a golden era in medical education at that center. Professor Ismail-Beigi invited outstanding teachers and physicians to collaborate with him. Their efforts during the next decade laid a strong and unique foundation for medical education based on quality mentorship and role-modeling. In this paper, we briefly highlight the importance of mentorship in medicine and medical education, followed by a glance at the academic life and career of Professor Ismail-Beigi and his role as a prominent mentor at the Shiraz School of Medicine

An incidentally swallowed toothbrush

Although foreign body [FB] ingestion is relatively common,ingestion of a toothbrush is rare. We are reporting on a 26-year old female who had accidentally swallowed a toothbrush which was successfully removed via endoscopy using a polypectomy snare

Dietary nitrate may have a role in development of gastro-esophageal reflux disease

Gastro-esophageal reflux disease [GERD] has become very common in the past three decades. The reason for this, as well as its exact pathophysiologic mechanisms are yet unknown. In this ecologic study we assessed the relation between water nitrate content and prevalence of GERD in Tehran, Iran. We determined the prevalence of acid regurgitation [AR] heartburn or any of them occurring on a frequent [at least weekly] or infrequent basis in areas with different water nitrate. The areas for nitrate were defined as below: <50mg nitrate/L, 50 - 74 mg/L, 75-100 mg/L, and >100 mg/L. Frequency of each symptom was assessed in each area and compared. Adjustment for age, sex, education, NSAID-consumption, BMI, smoking, history of GERD in first degree relatives and spouse was done in a multivariate model. People living in areas with water nitrate content more than 100mg/L had a higher chance of suffering from frequent AR than those living in areas with water nitrate less than 100mg/L [25.5% vs. 12.0%, OR: 2.53, 95% Cl: 1.36 - 4.73, P=0.006]. After adjustment for the named factors, the relationship remained significant [OR: 3.65, 95% Cl: 1.32 - 10.09]. The relation for frequent heartburn or infrequent symptoms was not significant. In this ecologic study, we found relation between experiencing frequent AR and drinking or cooking with water containing more than 100mg nitrate/L. Considering our current knowledge, if we put dietary nitrate into the puzzle of increased prevalence and/or pathophysi-ology of GERD, it can theoretically answer several questions. Hence we propose a nitrate-hypothesis for GERD pathogenesis

Eosinophilic gastroenteritis: a case series from Iran

Eosinophilic gastroenteritis [EG] is a rare inflammatory disorder of the gastrointestinal [GI] tract. There have been several case series of patients with EG from the western world and East Asia. However, there has not been a report of patients with EG from the Middle East region. The aim of this study is to describe clinical characteristics and treatment response in a series of EG patients from Iran. We retrospectively reviewed charts with a diagnosis of EG from 1997 to 2010 at Shariati Hospital and the private clinics of the authors. Clinical characteristics of the patients were evaluated, and the treatment response and relapse rate were assessed. Twenty-two patients [9 male] with EG were identified. Mean age of the patients was 45.1 +/- 15.5 [range: 27-75] years. Median duration between symptom onset and diagnosis was 12 [range 1- 48] months. Twenty [90%] patients had mucosal involvement, one [5%] had muscular involvement and one [5%] had subserosal involvement. Patients were followed for a median duration of 36.5 [range 4- 123] months. Two [90%] patients had mucosal involvement, one [5%] had muscular involvement and one [5%] had subserosal involvement. Patients were followed for a median duration of 36.5 [range 4-123] months. Two patients had spontaneous remission with supportive care. The remaining 20 patients responded well to oral corticosteroid treatments. The relapse rate was 33%. Episodes of relapse were successfully controlled with a repeat course of corticosteroids. Two patients with several relapses required maintenance treatment with azathioprine. The clinical characteristics and treatment responses of EG patients from Iran are similar to reports from other parts of the world. Patients need to undergo close follow up after treatment to detect early signs of relapse

Quality of life in reflux and dyspepsia [QOLRAD] questionnaire in Iranian patients with GERD: a validation study

Symptoms of gastro-esophageal reflux disease [GERD] affect health-related quality of life [HRQOL]. When a questionnaire is translated into a new language, linguistic validation is necessary, yet insufficient, unless the psychometric characteristics have been verified. The aim of this study is to document the translation and psychometric validation of the Persian translation of the Quality of Life in Reflux and Dyspepsia [QOLRAD] questionnaire. After translation and cultural adaptation of QOLRAD to Persian, fifty patients with clinical GERD from the Prospective Acid Reflux Study of Iran [PARSI] database who had at least one of the symptoms of acid regurgitation, heartburn, non-cardiac chest pain, or dysphagia for at least four weeks over the past three months completed the QOLRAD and Short Form Health Survey-36 [SF-36]. After two weeks, QOLRAD was again completed by the patients. Cronbach alpha and Intra-class Correlation Coefficient [ICC] were used to test reliability and Pearson correlation was used to compare the dimensions of SF-36 and QOLRAD. The translation was approved by MAPI Research Institute. Fifty patients completed the SF-36 and QOLRAD questionnaires at the first visit. Mean [SD] age of the participants was 38.4 [14.6] years and 68% were females. The internal consistency and reliability of QOLRAD ranged from 0.78-0.92. The test-retest reliability of QOLRAD was from 0.87-0.93. Relevant QOLRAD domains significantly correlated with the majority of SF-36 domains, with the exception of sleep disturbance. The psychometric characteristics of the Persian translation of QOLRAD were found to be good, with satisfactory reliability and validity

Thyroxine in goiter, helicobacter pylori infection, and chronic gastritis

Levothyroxine is absorbed between 62% and 72% from the jejunum and ileum. This intestinal absorption is pivotal to its clinical efficacy and is affected by several factors including age, adherence to therapy, dietary habits, absorption kinetics, malabsorption, interference of other drugs, and acid in the stomach. On the other hand Helicobacter pylori [HP] gastritis, corpus atrophic gastritis as well as patients receiving long-term proton pump inhibitors are rather frequent in western countries. We determined whether there is an increased need for thyroxine in patients with euthyroid multinodular goiter [MNG] and impaired secretion of gastric acid. We assessed the dose of thyroxine required to obtain a low level of thyrotropin [TSH, 0.05 to 0.20 mU per liter] in 248 patients with MNG. Of these 248 patients, 53 also had HP-related gastritis and 60 had atrophic gastritis [31 with evidence of HP infection and 29 without]. The reference group comprised 135 patients with MNG and no gastric disorders. In addition, variation in the level of serum TSH was prospectively studied in 11 patients treated with thyroxine before and after HP infection and both before and during treatment with omeprazole in 10 patients treated with thyroxine who had gastroesophageal reflux disease [GERD]. The daily requirement of thyroxine was higher [by 22 - 34%] in patients with HP-related gastritis, atrophic gastritis, or both conditions than in the reference group. In prospective studies, the occurrence of HP infection in the 11 patients treated with thyroxine led to an increase in the level of serum TSH [P = 0.002], an effect that was nearly reversed with HP eradication. In a similar way, omeprazole treatment was associated with an increase in the level of serum TSH in all 10 patients treated with thyroxine, an effect that was reversed by an increase in the thyroxine dose by 37%. Patients with impaired acid secretion require an increased dose of thyroxine, suggesting that normal gastric acid secretion is necessary for effective absorption of oral thyroxine