Cascade colorectal cancer screening guidelines: a global conceptual model.

BACKGROUND: Guidelines should be a catalyst toward achieving, as a universal standard, the most effective possible care. However, guidelines mainly use evidence of effectiveness as the basis for recommendations. This approach may not be the most appropriate for all healthcare settings because of differing levels of available medical and financial resources. This report from the Guidelines Committee of the World Gastroenterology Organization presents a new conceptual model of cascade colorectal cancer screening guidelines that is also evidence based but resource driven. The emphasis in this variation of the model is on colonoscopy resources at the top of the cascade for a screening goal of prevention by finding and removing the colorectal cancer precursor lesions, the adenoma, as well as early detection. This is a concept study for consideration in the development of future guidelines. Various tests can be reordered within the framework of this model. The cascade concept says, "do what you can with what you have," rather than, "do it this way or no way." METHODS: A systematic review of colorectal cancer screening was performed and an evidence-based cascade (hierarchical recommendations) developed that could apply to healthcare settings having different levels of medical (primarily colonoscopy in this version of the model) resources. A review team representing both developed and developing countries examined published data and provided expert opinion. Cascade guidelines were prepared and reviewed by the team. RESULTS: A set of 4 resource levels were delineated based on available data: colonoscopy, sigmoidoscopy, different sensitivity fecal occult blood tests, and recommendations for colorectal cancer screening were made based on each level, from high to low resources for average risk men and women. The major resource considered was endoscopic in this version of the model. CONCLUSIONS: Each country, region, or healthcare setting needs to determine whether colorectal cancer screening is a legitimate consideration based on other healthcare priorities. Where there is a major burden of colorectal cancer and sufficient resources to mount a screening program, the cascade colorectal cancer screening guidelines model can assist in decisions regarding screening methods. This version is based mainly on available endoscopic resources. These guidelines are evidence based but resource driven. Each healthcare setting needs to determine its resource level as a basis for selecting the screening approach that is most applicable and therefore most likely to succeed. This concept study provides a model that can be adapted to a variety of evidence-based options with consideration of available resources. Its goal is to enhance colorectal cancer screening worldwide, especially in developing countries where the colorectal cancer incidence and mortality is rising rapidly.

[Virtual room of gastroenterology]. / Aula virtual de gastroenterologia.

The amount of published information and its continuing growth can no longer be managed by an individual searcher. One of today's great challenges for the academic researcher and clinician is to find a relevant scientific article using bibliographic search strategies. We aimed to design and build a Virtual Room of Gastroenterology (VRG) generating real-time automated search strategies and producing bibliographic and full text search results. These results update and complement with the latest evidence the Clinical Guideline Program of the World Gastroenterology Organisation. The HTML driven interface provides a series of pre-formulated MeSH based search strategies for each Aula. For each topic between 10 and 20 specific terms, qualifiers and subheadings are identified. The functionality of the VRG is based on the PubMed's characteristic that allows a search strategy to be captured as a web address. The VRG is available in Spanish and English, and the access is free. There are 28 rooms currently available. All together these rooms provide an advanced bibliographic access using more than 900 pre-programmed MeSH driven strategies. In a further very recent development some of the topics of VRG now allow cascade based searches. These searches look at resource sensitive options and possible ethnic difference per topic. The VRG allows significant reductions in time required to design and carry out complex bibliographic searches in the areas of gastroenterology, hepatology and endoscopy. The system updates automatically in real-time thus ensuring the currency of the results.

Gastroenterology in developing countries: issues and advances.

Developing countries shoulder a considerable burden of gastroenterological disease. Infectious diseases in particular cause enormous morbidity and mortality. Diseases which afflict both western and developing countries are often seen in more florid forms in poorer countries. Innovative techniques continuously improve and update gastroenterological practice. However, advances in diagnosis and treatment which are commonplace in the West, have yet to reach many developing countries. Clinical guidelines, based on these advances and collated in resource-rich environments, lose their relevance outside these settings. In this two-part review, we first highlight the global burden of gastroenterological disease in three major areas: diarrhoeal diseases, hepatitis B, and Helicobacter pylori. Recent progress in their management is explored, with consideration of future solutions. The second part of the review focuses on the delivery of clinical services in developing countries. Inadequate numbers of healthcare workers hamper efforts to combat gastroenterological disease. Reasons for this shortage are examined, along with possibilities for increased specialist training. Endoscopy services, the mainstay of gastroenterology in the West, are in their infancy in many developing countries. The challenges faced by those setting up a service are illustrated by the example of a Nigerian endoscopy unit. Finally, we highlight the limited scope of many clinical guidelines produced in western countries. Guidelines which take account of resource limitations in the form of "cascades" are advocated in order to make these guidelines truly global. Recognition of the different working conditions facing practitioners worldwide is an important step towards narrowing the gap between gastroenterology in rich and poor countries.

[Why are there few publications by the Argentine gastroenterology? Considerations on a bibliometric analysis of Argentine publications on gastroenterology]. / Por qué publica poco la gastroenterología Argentina? Consideraciones sobre un análisis bibliométrico de publicaciones Argentinas en gastroenterología.

The publication of scientific findings is the main way to communicate advances. Our aim was to perform a bibliometric and comparative analysis of the Argentinean gastroenterological research output. We analyzed Argentinean gastroenterological publications selectively retrieved from LILACS (between years 1982-2006) and EMBASE (1996-2007) databases by means of specially constructed filter based on author address and subject headings. The global Argentinean scientific research output is far below that of developed countries and has been affected in direct manner by economic, political and social disturbances in the country. The gastroenterological research output from Argentina represent about 6% of national biomedical research. While 54% belongs to gastroenterology and 46% to hepatology, 65% are based on clinical research and 67% were originally contributions. Only 11% have been published in high impact factor journals. The comparative analysis within countries with health indicators similarities has shown a low biomedical and gastroenterology research output, however, the rate of acceptance at the 18 top gastroenterological journals is acceptable (15%). The contributions of registered specialists were lower for gastroenterologists compared with those from hepatologists (8.7% and 16.4% respectively). The research projects at public hospital funded by the pharmaceutical industry overcome those funded independently. Indeed, it seems that the independent research is being progressively replaced by that supported by the industry due to economic benefits for researchers even when there is a very low participation rate in publications (3%) by Argentinean researchers. We conclude that the Argentinean biomedical and gastroenterological research output is scanty compared with developed countries and countries with comparable health indicators. Our analysis suggests that efforts must be taken to attain objectives directed to develop and improve the Argentinean biomedical and gastroenterological scientific work and publication.

Can 'Cascades' make guidelines global?

Why are guidelines in medicine so important today? What role do they have? Why and how did the World Gastroenterology Organization (WGO) choose a global focus? What does this mean for guidelines? These are the underlying questions addressed by our article. We argue that the addition of 'Cascades' to guidelines will increase their impact in large parts of the world. By so doing, we hope to add a new dimension to the 'knowledge into action' debate. A number of illustrations shows how raised expectations and resource restrictions pose - or should pose - an enormous challenge for guideline makers. Furthermore, the emphasis on evidence also creates problems for guideline making. If resources are limited it is unlikely gold-standard technologies are available. We believe Cascades can help. A Cascade is a selection of two or more hierarchical diagnostic or therapeutic options, based on proven medical procedures, methods, tools or products for the same disease, condition or diagnosis, aiming to achieve the same outcome and ranked by available resources. The construction of such a cascade is a hazardous intellectual journey that goes, to some extent, against established practice. But lives can be saved by matching options for diagnosis and treatment to available resources. While the optimal strategy, defined through an evidence-based approach, should always be the goal, one must be aware of the resource limitations that confront our colleagues in certain parts of the world and we should endeavour to work with them in the guideline development process to develop strategies that are clinically sound yet economically feasible and dacceptable to their populace.