Patients with computed tomography-proven acute diverticulitis require follow-up to exclude colorectal cancer.

BACKGROUND/AIMS: Traditionally, patients with acute diverticulitis undergo follow-up endoscopy to exclude colorectal cancer (CRC). However, its usefulness has been debated in this era of high-resolution computed tomography (CT) diagnosis. We assessed the frequency and outcome of endoscopic follow-up for patients with CT-proven acute diverticulitis, according to the confidence in the CT diagnosis. METHODS: Records of patients with CT-proven acute diverticulitis between October 2007 and March 2014 at Sandwell & West Birmingham Hospitals NHS Trust were retrieved. The National Cancer Registry confirmed the cases of CRC. Endoscopy quality indicators were compared between these patients and other patients undergoing the same endoscopic examination over the same period. RESULTS: We identified 235 patients with CT-proven acute diverticulitis, of which, 187 were managed conservatively. The CT report was confident of the diagnosis of acute diverticulitis in 75% cases. Five of the 235 patients were subsequently diagnosed with CRC (2.1%). Three cases of CRC were detected in the 187 patients managed conservatively (1.6%). Forty-eight percent of the conservatively managed patients underwent follow-up endoscopy; one case of CRC was identified. Endoscopies were often incomplete and caused more discomfort for patients with diverticulitis compared with controls. CONCLUSIONS: CRC was diagnosed in patients with CT-proven diverticulitis at a higher rate than in screened asymptomatic populations, necessitating follow-up. CT reports contained statements regarding diagnostic uncertainty in 25% cases, associated with an increased risk of CRC. Follow-up endoscopy in patients with CT-proven diverticulitis is associated with increased discomfort and high rates of incompletion. The use of other follow-up modalities should be considered.

Conversion of colonoscopy to flexible sigmoidoscopy: an unintended consequence of quality measurement in endoscopy.

OBJECTIVE: To quantify the proportion of requests for colonoscopy that are performed as flexible sigmoidoscopy and documented reasons for this in ordinary UK hospital practice. To determine the effect these requests have on colonoscopy completion rate if they are included in the denominator of the calculated rate by individual endoscopist. DESIGN: Retrospective study of 22 months flexible sigmoidoscopy practice at a major UK teaching hospital. All flexible sigmoidoscopies performed had their associated request form examined. SETTING: UK NHS University Hospital. PATIENTS: All patients receiving outpatient flexible sigmoidoscopy from January 2013 to October 2014 with no exclusions. INTERVENTION: Conversion of colonoscopy to flexible sigmoidoscopy. MAIN OUTCOME MEASURES: Conversion of colonoscopy to flexible sigmoidoscopy, reason for conversion and adjusted colonoscopy completion rate. RESULTS: 71 of the 3526 flexible sigmoidoscopies performed (2.0%), representing 71 of 5905 colonoscopy requests (1.2%). Conversion reason was noted only in 26 (37%) of converted cases. Adjustment of colonoscopy completion rate to include conversions pushed four of our unit's 22 endoscopists below the UK national 90% standard. CONCLUSIONS: Conversion to flexible sigmoidoscopy occurs in 1.2% of patients originally booked for colonoscopy. The reason for this conversion is often unqualified and may be inappropriate. Conversion can affect the colonoscopy completion rate, and therefore, should be included in endoscopists' overall performance statistics.

An analysis of the learning curve to achieve competency at colonoscopy using the JETS database.

OBJECTIVE: The number of colonoscopies required to reach competency is not well established. The primary aim of this study was to determine the number of colonoscopies trainees need to perform to attain competency, defined by a caecal intubation rate (CIR) ≥90%. As competency depends on completion, we also investigated trainee factors that were associated with colonoscopy completion. DESIGN: The Joint Advisory Group on GI Endoscopy in the UK has developed a trainee e-portfolio from which colonoscopy data were retrieved. Inclusion criteria were all trainees who had performed a total of ≥20 colonoscopies and had performed ≤50 colonoscopies prior to submission of data to the e-portfolio. The primary outcome measure was colonoscopy completion. The number of colonoscopies required to achieve CIR ≥90% was calculated by the moving average method and learning curve cumulative summation (LC-Cusum) analysis. To determine factors which determine colonoscopy completion, a mixed effect logistic regression model was developed which allowed for nesting of patients within trainees and nesting of patients within hospitals, with various patient, trainee and training factors entered as fixed effects. RESULTS: 297 trainees undertook 36 730 colonoscopies. By moving average analysis, the cohort of trainees reached a CIR of 90% at 233 procedures. By LC-Cusum analysis, 41% of trainees were competent after 200 procedures. Of the trainee factors, the number of colonoscopies, intensity of training and previous flexible sigmoidoscopy experience were significant factors associated with colonoscopy completion. CONCLUSIONS: This is the largest study to date investigating the number of procedures required to achieve competency in colonoscopy. The current training certification benchmark in the UK of 200 procedures does not appear to be an inappropriate minimum requirement. The LC-Cusum chart provides real time feedback on individual learning curves for trainees. The association of training intensity and flexible sigmoidoscopy experience with colonoscopy completion could be exploited in training programmes.

Intra-articular corticosteroid injections in the foot and ankle: a prospective 1-year follow-up investigation.

UNLABELLED: Most evidence for the efficacy of intra-articular corticosteroids is confined to the knee, with few studies considering the joints of the foot and ankle. The aim of this study was to identify the long-term efficacy of corticosteroid injection in foot and ankle joints. All patients undergoing intra-articular corticosteroid injections into foot and ankle joints over a 10-month period were recruited into the study. Patients were asked to complete a foot-related quality of life questionnaire, namely the Foot and Ankle Outcome Score, immediately before intra-articular injection and at set points up to 1-year afterward. Eighteen patients, comprising 36 foot and ankle joints, were recruited into the study. There was a statistically significant score improvement following corticosteroid injection up to and including 6 months postinjection. No independent clinical factors were identified that could predict a better postinjection response. The magnitude of the response at 2 months was found to predict a sustained response at 9 months and 1 year. Intra-articular corticosteroids improved symptom scores in patients with foot and ankle arthritis. The duration of this response was varied and patient factors affecting the response remain unclear. Response to the injection at 2 months can be used to predict the duration of beneficial effects up to at least 1 year. LEVEL OF CLINICAL EVIDENCE: 2.