Quality assurance of endoscopy units.

This chapter reflects on how England has led the world in service development and quality assurance of endoscopy. It draws out themes of leadership, strategic vision and organisational culture. It emphasises the pivotal importance of focussing service improvement on enhancing the quality of a patient's experience of endoscopy. It describes the processes used here for quality assurance of endoscopy units and how these have dovetailed with other strands of work in transforming the English endoscopy service. The chapter presents discussion of the responses to accreditation processes and how the design of the JAG Accreditation process maximises its effectiveness.

Predictive and prognostic factors in colorectal cancer: a personalized approach.

It is an exciting time for all those engaged in the treatment of colorectal cancer. The advent of new therapies presents the opportunity for a personalized approach to the patient. This approach considers the complex genetic mechanisms involved in tumorigenesis in addition to classical clinicopathological staging. The potential predictive and prognostic biomarkers which have stemmed from the study of the genetic basis of colorectal cancer and therapeutics are discussed with a focus on mismatch repair status, KRAS, BRAF, 18qLOH, CIMP and TGF-ß.

Colorectal cancer detection by measuring DNA from exfoliated colonocytes obtained by direct contact with rectal mucosa.

The purpose of the study was to explore the potential of direct exfoliated colonocyte collection from human rectal mucosa for colorectal cancer screening. A special device was designed for standardized collection of exfoliated cells from the surface of human rectal mucosa. Material was collected from 120 outpatients selected for colonoscopy and 36 patients with confirmed diagnosis of colorectal cancer or large polyps. Determination of total DNA amounts in the collected samples (DNA scores) by PicoGreen assay and real-time PCR was employed alongside cytological assessment. Well preserved cells with cytological patterns characteristic for different colorectal conditions (cancer, inflammatory bowel disease) were detected in the collected material. In the outpatient group DNA scores were higher in patients with cancer and inflammatory bowel disease compared to those with no abnormalities detected, diverticular disease and small polyps (P<0.001 for PicoGreen assay; P=0.002 for real-time PCR). The sensitivity and specificity of the quantitative DNA test (PicoGreen assay; cut-off point 3.0 microg/ml) for detecting serious colorectal conditions were 1.00 and 0.74, respectively. In the group with confirmed tumours, the PicoGreen assay performed better for distal colorectal cancer (sensitivity 0.83; specificity 0.76) compared with proximal colon malignancies (sensitivity 0.57; specificity 0.76). It can be concluded that the proposed technique of direct collection of exfoliated cells from the surface of human rectal mucosa provides abundant cellular material suitable for diagnostic and research applications. Further refinement of the quantitative DNA test may lead to a new approach for colorectal cancer early detection and screening.

Failure to gain weight on long-term parenteral nutrition attributed to tri-iodothyronine thyrotoxicosis.

We describe the case of a 49-y-old female patient on long-term parenteral nutrition after abdominal surgery who failed to gain weight despite nutritional provision in excess of theoretical requirements. On investigation, she was found to have a negative nitrogen balance (-5.9 g) and to have a tri-iodothyronine thyrotoxicosis but without many of the typical clinical features of hyperthyroidism. The patient also had mild hypercalcemia and hyperphosphatemia, which resolved fully after mobilization and treatment of the thyrotoxicosis. A derangement of the liver function tests was observed, which worsened progressively during parenteral nutrition but resolved promptly at its discontinuation. This case illustrates the importance of carrying out appropriate investigations including all thyroid function tests on patients who fail to gain weight on nutritional support.