Exploring the Diagnostic Spectrum of Children with Raised Faecal Calprotectin Levels.

Faecal calprotectin (FC) is a marker of gut inflammation. The cause and relevance of raised FC in children outside the context of established inflammatory bowel disease (IBD) have had minimal attention. This study aimed to address this by carrying out a retrospective study on children with abnormal FC tests aged 4-17 years without established IBD in the South Island, New Zealand. Abnormal FC results were stratified: 51-249 µg/g, 250-499 µg/g, and 500+ µg/g, and participants were categorised into diagnostic groups. Data were collected on symptoms and diagnostic tests. Three-hundred and ten children had abnormal index FC results, with a mean age of 12.9 years, and a 55% proportion of females. The median FC was 125 µg/g; 71% had levels 51-249 µg/g and 21% had levels 500+ µg/g. Of those with FC 500+ µg/g, 89% either had infectious diarrhoea or were diagnosed with IBD at the time of, or subsequent to, the index FC. Alarm symptoms did not delineate between groups with FC 500+ µg/g. Abnormalities in platelet levels, abdominal ultrasound, and colonoscopy were more frequent for children diagnosed with IBD. Repeat FC test levels were significantly reduced except for those subsequently diagnosed with IBD. Abnormal FC levels for the majority were below the level indicative of mucosal inflammation. Repeat FC testing could play an important role in distinguishing between diagnoses.

The Swedish Standardized Course of Care-Diagnostic Efficacy in Esophageal and Gastric Cancer.

Fast-track pathways for diagnosing esophageal or gastric cancer (EGC) have been implemented in several European countries. In Sweden, symptoms such as dysphagia, early satiety, and other alarm symptoms call for a referral for gastroscopy, according to the Swedish Standardized Course of Care (SCC). The aim of this study was to evaluate the diagnostic yield of the SCC criteria for EGC, to review all known EGC cases in Region Örebro County between March 2017 and February 2021, and to compare referral indication(s), waiting times, and tumor stage. In our material, EGC was found in 6.2% of the SCC referrals. Esophageal dysphagia had a positive predictive value (PPV) of 5.6%. The criterion with the highest PPV for EGC was suspicious radiological findings, with a PPV of 24.5%. A total of 139 EGCs were diagnosed, 99 (71%) through other pathways than via the SCC. Waiting times were approximately 14 days longer for patients evaluated via non-SCC pathways. There was no statistically significant association between referral pathway and primary tumor characteristics. The results show that a majority of the current SCC criteria are poor predictors of EGC, and some alarm symptoms lack a sufficiently specific definition, e.g., dysphagia. Referral through this fast track does not seem to have a positive impact on disease outcomes.

[Frequent Gastro-Intestinal Disorders: Management of Functional Dyspepsia and Irritable Bowel Syndrome in Clinical Practice]. / Häufige Magen-Darm-Beschwerden: Management der funktionellen Dyspepsie und des Reizdarm-Syndroms in der Praxis.

Frequent Gastro-Intestinal Disorders: Management of Functional Dyspepsia and Irritable Bowel Syndrome in Clinical Practice Abstract: Functional dyspepsia (FD) and irritable bowel syndrome (IBS), two common gastrointestinal entities with overlapping symptoms, should be diagnosed according to Rome IV criteria. This includes one or more of the following symptoms: in FD, postprandial fullness, early satiation, epigastric pain or burning; in IBS, recurrent abdominal pain associated with defecation, change in frequency of stool or form of stool. To exclude structural diseases, attention should be paid to alarm symptoms. As far as treatment is concerned, a stepwise scheme proves to be effective for both diseases. Step 1: doctor-patient discussion with explanation of diagnosis and prognosis as well as clarification of therapy goals; lifestyle adaptations; use of phytotherapeutics; step 2: symptom-oriented medication: for FD, PPIs or prokinetics; for IBS, antispasmodics, secretagogues, laxatives, bile acid sequestrants, antidiarrheals, antibiotics, probiotics; step 3: visceral analgesics (antidepressants).

Belching as a symptom of COVID-19: Case presentation / Eructo como síntoma de la COVID-19: Presentacion de caso / Arrotos como um sintoma de COVID-19: Apresentação do caso

Introduction: The main symptoms of this viral infection are fever, dry cough and shortness of breath, but there is an increase in the report of cases of COVID-19 that presented gastrointestinal symptoms and evolved towards severity. Objective: To present a patient with SARS-CoV-2 infection who, from gastrointestinal manifestations, progressed to stages of disease severity and death. Case presentation: Male patient, 55 years old, with a history of high blood pressure for which he was following a treatment schedule with captopril (25 mg) 1 tablet twice a day. He began with general malaise and persistent belching, lasting several hours, fever appeared on the third day and a diagnosis of SARS CoV-2 infection was made . The next day, respiratory distress appeared suddenly while the aforementioned symptoms persisted and the patient progressed to acute respiratory distress syndrome, supported by ventilatory support, but died despite this. Conclusions: Gastrointestinal manifestations are not so infrequent, knowledge of these manifestations allows us to be alert during follow-up and establish an early diagnosis with the aim of reducing complications and the mortality rate in patients with atypical presentations of the disease.

Introducción: Los síntomas principales de esta infección viral son fiebre, tos seca y falta de aire, pero existe un incremento en el reporte de casos de COVID-19 que presentaron síntomas gastrointestinales y evolucionaron hacia la gravedad. Objetivo: Presentar un paciente con infección por SARS-CoV-2 que a partir de las manifestaciones gastrointestinales evolucionó a los estadios de gravedad de la enfermedad y muerte. Presentación de caso: Paciente masculino, de 55 años de edad, con antecedentes de hipertensión arterial para lo cual cumplía esquema de tratamiento con captopril (25 mg) 1 tableta dos veces al día. Comenzó con malestar general y eructos persistentes, de varias horas de evolución, al tercer día apareció la fiebre y se realizó diagnóstico de infección por SARS CoV-2. Al siguiente día la dificultad respiratoria aparece de forma súbita mientras se mantenían los síntomas antes mencionados y el paciente evoluciona al síndrome de dificultad respiratoria agudo, se apoya con soporte ventilatorio, pero a pesar de ello fallece. Conclusiones: Las manifestaciones gastrointestinales no son tan infrecuentes, el conocimiento de estas manifestaciones permite estar alertas en el seguimiento y establecer un diagnóstico precoz con el objetivo de disminuir las complicaciones y la tasa de mortalidad en pacientes con presentaciones atípicas de la enfermedad.

Introdução: Os principais sintomas dessa infecção viral são febre, tosse seca e falta de ar, porém há um aumento no relato de casos de COVID-19 que apresentaram sintomas gastrointestinais e evoluíram para gravidade. Objetivo: Apresentar um paciente com infecção por SARS-CoV-2 que, a partir de manifestações gastrointestinais, evoluiu para estágios de gravidade da doença e óbito. Apresentação do caso: Paciente do sexo masculino, 55 anos, com histórico de hipertensão arterial para o qual seguia esquema terapêutico com captopril (25 mg) 1 comprimido duas vezes ao dia. Começou com mal-estar geral e arrotos persistentes, com duração de várias horas, no terceiro dia apareceu febre e foi feito o diagnóstico de infecção por SARS CoV-2. No dia seguinte, o desconforto respiratório apareceu subitamente enquanto os sintomas mencionados persistiam e o paciente evoluiu para síndrome do desconforto respiratório agudo, sustentado por suporte ventilatório, mas morreu apesar disso. Conclusões: As manifestações gastrointestinais não são incomuns, o conhecimento destas manifestações permite-nos estar atentos no seguimento e estabelecer um diagnóstico precoce com o objetivo de reduzir as complicações e a taxa de mortalidade em doentes com apresentações atípicas da doença.

Involvement of personal and professional relations when experiencing colorectal cancer symptoms - a cross sectional study.

OBJECTIVE: As part of improving early diagnosis of colorectal cancer (CRC), knowledge about involvement of personal and professional relations, when experiencing CRC symptoms, is important. This study aimed to analyse involvement of personal and professional relations and whether age, sex, number of symptoms and available social network are associated with involving family, non-family and professional relations amongst individuals experiencing CRC symptoms. METHODS: Some, 100 000 Danes over 20 years were randomly selected and invited to a cross sectional survey comprising questions about involvement of relations regarding four predefined CRC symptoms (abdominal pain, rectal bleeding and change in stool texture and frequency). RESULTS: In total, 35 801 respondents over 40 years answered all relevant items and 9346 (26.1%) had experienced at least one CRC symptom in the preceding 4 weeks. Abdominal pain was more often than stool-related symptoms discussed with relations. Respondents with >1 symptom had higher odds of reporting general practitioner (GP) contact compared to respondents with single symptoms. Age ≥60 years was associated with higher odds of GP contact and involving family relations. Spouse/partner was the most frequently involved relation. Involving a personal relation increased the odds of GP contact. Having an available social network decreased GP contact for some symptoms. CONCLUSION: Odds of involving professional relations, e.g. the GP, were higher amongst individuals experiencing multiple CRC symptoms and those involving personal relations. Having an available social network was associated with lower odds of GP contact, suggesting that individuals with no available social network are more prone to use their GP.

Is concern for gynaecological alarm symptoms associated with healthcare-seeking? A Danish population-based cross-sectional study.

BACKGROUND: Diagnosing cancer at an early stage increases survival, and for most gynaecological cancers the diagnostic pathway is initiated, when women seek medical attention with symptoms. As many factors influence healthcare-seeking, knowledge about these factors is important. Concern can act as a barrier or a trigger for women experiencing gynaecological alarm symptoms. This study aimed to examine whether concern for the symptom or the current health was associated with healthcare-seeking among women with gynaecological alarm symptoms. METHODS: Some 100,000 randomly selected Danish citizens were invited to a national web-based survey. The questionnaire included items regarding symptom experiences, healthcare-seeking and concern for the experienced symptoms and current health. This study included 5019 women with self-reported gynaecological alarm symptoms (pelvic pain, pain during intercourse, bleeding during intercourse and postmenopausal bleeding). Concern was reported on a 5-point Likert scale from 'not at all' to 'extremely'. Data were analysed using multivariate logistic regression models. RESULTS: Women who were 'extremely' concerned about a gynaecological alarm symptom had two to six times higher odds of reporting healthcare-seeking compared to women who were 'not at all' concerned. Symptom concern was associated with higher odds of healthcare-seeking for all four gynaecological alarm symptoms and the odds increased with increasing levels of concern. Additionally, concern for current health was associated with higher odds of healthcare-seeking. Concern for current health as expressed by others was positively associated with healthcare-seeking but had only minor influence on the association between concern for current health and healthcare-seeking. CONCLUSIONS: Concern for a gynaecological alarm symptom and for current health was positively associated with healthcare-seeking. The results can be used for future informational health campaigns targeting individuals at risk of postponing warranted healthcare-seeking.

Chronic Constipation: Gastroenterohepatologist's Approach.

BACKGROUND: Constipation is a common problem in gastroenterological practice. The prevalence of constipation is about 16%. Constipation can be primary or secondary. SUMMARY: The diagnostic and therapeutic approach to patients with constipation begins with a detailed history and physical examination. In selected cases, the use of additional diagnostic procedures is very important. This includes the use of laboratory, endoscopic, and radiological examinations, as well as advanced physiological testing (anorectal manometry, balloon expulsion test, colonic transit studies, and defecography). Constipation therapy can be both nonoperative and operative. Nonoperative therapy includes the application of a lifestyle measures, pharmacotherapy and biofeedback therapy. Key Messages: Two key things when taking a medical history and physical examination are to rule out the existence of alarm symptoms/signs and to rule out secondary constipation (primarily drug-induced). Therapy begins with lifestyle modification, and in case of failure, bulk or osmotic laxatives are used. In case of failure, the use of lubiprostone is indicated, as well as linaclotide. Surgical treatment of constipation is reserved for cases of refractory constipation, with delayed intestinal transit.

Dyspepsia Challenge in Primary Care Gastroenterology.

BACKGROUND: The purpose of this review is to take a deep dive into general problems and challenges of diagnosis and treatment of patients with symptoms of dyspepsia in primary care practice. SUMMARY: Primary care physicians become acquainted with a broad range of clinical problems and therefore require a wide span of knowledge in taking care of patients from their first medical examination within the health care system. Dyspepsia and Helicobacter pylori infection are two of the most frequent reasons of digestive-related health care issues, despite that in primary care practice, current recommendations for diagnosis and differential therapy are often not implemented. The "test-and-treat" strategy is the initial management of the condition, reserving gastroscopy for patients refractory to symptomatic treatment and for patients presenting with any of the following alarm signs: age of above 55, dysphagia, anemia, weight loss, frequent vomiting, family history of GI malignancy, or a physical examination with key pathological findings. KEY MESSAGES: Examination and treatment of dyspepsia symptoms is the diagnostic and therapeutic challenge dictated by organizational and economic potentials of the health system, professional resources, and primary health care capabilities to accept and treat patients with dyspepsia and to properly refer those with alarm symptoms and findings indicative of organic disease to a gastroenterologist.

Making a Confident Diagnosis of Irritable Bowel Syndrome.

Irritable bowel syndrome (IBS) is among the most common diagnoses made by medical providers and its symptoms are common causes for health care consultation. IBS is characterized by abdominal pain associated with abnormal stool consistency and/or frequency and is widely considered a diagnosis of exclusion, despite abundant evidence contradicting such an approach. A positive diagnosis is achieved through application of symptom-based clinical criteria, careful history and physical examination, evaluation for alarm sign/symptoms, and judicious use of diagnostic testing. This article reviews the symptom-based criteria for IBS and utility of diagnostic tests commonly included in the evaluation of IBS symptoms.

Diagnostic utility of alarm features in predicting malignancy in patients with dyspeptic symptoms.

BACKGROUND: Clinical features are of modest benefit in determining the etiology of dyspepsia. Dyspeptic patients with alarm features are suspected to have malignancy; but the proportions of patients and true cutoff values of various quantitative parameters in predicting malignancy are explored to a lesser extent. METHODS: This is a prospective observational study of consecutive patients undergoing esophagogastroduodenoscopy (EGD) for dyspeptic symptoms. Patients' alarm features and clinical details were recorded in a predesigned questionnaire. The diagnostic accuracy of alarm features in predicting malignancy was studied. RESULTS: Nine hundred patients, 678 (75.3%) males, with a mean (standard deviation [SD]) age of 44.6 (13.54) years were enrolled. Commonest indication for EGD was epigastric pain in 614 (68.2%) patients. Dyspepsia was functional in 311 (34.6%) patients. EGD revealed benign lesions in 340 (37.8%) and malignancy in 50 (5.5%) patients. Among the malignant lesions, gastric malignancy was present in 28 (56%) and esophageal malignancy in 20 (40%) patients. Alarm features were present in 206 (22.9%), out of which malignant lesions were seen in 46 (22.3%) patients. Altogether, the alarm features had a sensitivity of 92% and specificity of 81.2% for predicting malignancy. The sensitivity and specificity for weight loss were 76% and 90.8%, while that of abdominal mass were 10% and 99.9% respectively. Based on receiver operating characteristic curve, the optimal age for screening of malignancy was 46.5 years in this population. CONCLUSIONS: Patients of age group 40 to 49 years with dyspeptic alarm symptoms (predominant weight loss) need prompt endoscopy to screen for malignancy. The alarm features are inexpensive screening tools, found to be useful in India, and should be utilized in countries with similar healthcare conditions and disease epidemiology.

The predictive value of 'red flags' as milestones of psychomotor development of premature babies - preliminary study.

INTRODUCTION: Premature babies are a special group at risk of persistent brain damage caused by diseases, the most serious of which are cerebral palsy(CP), autism spectrum disorders (ASD) and mental retardation, among others. These conditions may occur concurrently, but appear more often as separate disease syndromes in the same group of at-risk children. Long-term observation of psychomotor development by an interdisciplinary medical team closely cooperating with parents is necessary. It is important to detect the risk of developing these diseases as soon as possible in all development spheres. MATERIAL AND METHODS: The research was conducted to demonstrate the prognostic value of 'red flags' of developmental milestones and the ability to detect early signs of risk of developing CP and ASD in extremely premature babies. In this preliminary study, 42 preterm babies, born after less than 32 weeks pregnancy participated. RESULTS: The occurrence of 'red flags'in the spheres: gross motor, fine motor and cognitive at 9 months was strongly associated with their presence at 24 months. The sensitivity and specificity were: gross motor - 0.91 (95% CI: 0.59, 1.00) and 0.94 (95% CI: 0.79, 0.99); fine motor - 0.83 (95% CI 0.36-1.00) and 1.00 (95% CI: 0.90-1.00); cognitive - 1.00 (0.40, 1.00) and 0.97 (0.86, 1.00). Other spheres had lower sensitivity but high specificity. CONCLUSIONS: The conclusion is that the 'red flags'at the 9 months milestones already predict the normal or developmental delay of premature babies, and predict the risk of CP and ASD. Due to the availability and lack of the need for specialized and costly training, it is worth considering their use in everyday life medical practice.

Incidence and risk factors for preneoplastic and neoplastic lesions of the colon and rectum in patients under 50 referred for colonoscopy.

BACKGROUND: Colorectal cancer (CRC) diagnosed before the age of 50, known as early-onset CRC (eoCRC), is considered uncommon. We aimed at analysing the incidence of preneoplastic and neoplastic lesions of the colon and rectum in patients under 50 years old and to identify possible predictors Methods: We retrospectively collected data from 1778 patients under 50 years old (mean age 39.9±7.8) referred for colonoscopy between 2015-2018. Cumulative incidence of adenomas and eoCRC was assessed. Multivariable regression models were fitted Results: The cumulative incidence for adenomas was 11.0% (95% CI 9-12), while it was 1.5% (95% CI 1-2) for eoCRC (metastatic disease in 13/27 patients). Age as a continuous variable was associated with the presence of adenomas (incidence rate ratio 1.06; 95% CI 1.03-1.09; p<0.001). EoCRC arose in most cases in the rectum (13/27, 48.1%). Age ≥40 was the main risk factor (OR 2.25; 95% CI 1.35-3.73; p=0.002) for both adenomas (160/196 patients, 81.6%) and eoCRC (20/27 patients, 74.1%), while smoking seemed to have no role (p=0.772). The presence of alarm symptoms was statistically significant at bivariable analysis for eoCRC only (OR 3.70; 95% CI 1.49-9.22; p=0.005), as well as having multiple gastrointestinal symptoms (OR 19.85; 95% CI 2.64-149.42; p=0.004). Only 3/27 (11.1%) patients with eoCRC had a family history for CRC Conclusions: A high cumulative incidence rate of both adenomas and eoCRC was found, this latter occurring more common in patients aged 40-49, without apparent risk factors. The presence of alarm symptoms or multiple gastrointestinal symptoms led to a late diagnosis.

Reflux Symptoms - Functional and Structural Diseases: The Approach from the General Practitioner.

A primary care management strategy of gastroesophageal reflux disease (GERD) should pay attention to the epidemiology, prevalence, and distribution of reflux-like symptoms in the community and to the special characteristics of patients presenting for the first time with reflux symptoms in primary care. General practitioners (GPs) encounter daily challenges to make cost-effective differential diagnostic and therapeutic decisions, avoiding needless and costly investigation or referral. They should provide long-term effective control of symptoms and esophageal healing in a personalized, symptom-based, patient-centered, and evidence-based manner. GPs should use a practical system of triage in order to distinguish the high majority of patients with self-limiting conditions from the minority with alarm symptoms with potentially severe disorder. They should also discriminate between troublesome and nontroublesome reflux symptoms. Most GERD is uncomplicated and can be treated using management algorithms that make the best use of resources. Some strategies such as "step-down," "intermittent," or "on-demand" therapy can cost-effectively improve the long-term management and quality of life of patients with recurrent GERD. The accurate interpretation of "step-down" therapeutic strategy and a careful interpretation of proton pump inhibitor refractoriness are also essential.

Predictive value of alarm symptoms in patients with Rome IV dyspepsia: A cross-sectional study.

BACKGROUND: No studies have evaluated the predictive value of alarm symptoms for organic dyspepsia and organic upper gastrointestinal (GI) diseases based on Rome IV criteria in the Chinese population. AIM: To evaluate the predictive value of alarm symptoms for dyspeptic patients based on Rome IV criteria. METHODS: We performed a cross-sectional study of dyspepsia patients who met the inclusion and exclusion criteria at two academic urban tertiary-care centers from March 2018 to January 2019. Basic demographic data, dyspeptic information, alarm symptoms, lifestyle, examination results, family history and outpatient cost information were collected. Dyspepsia patients with normal findings on upper GI endoscopy, epigastric ultrasound and laboratory examination and without Helicobacter pylori-associated dyspepsia were classified as functional dyspepsia. RESULTS: A total of 381 patients were enrolled in the study, including 266 functional dyspepsia patients and 115 organic dyspepsia patients. There were 24 patients with organic upper GI disease among patients with organic dyspepsia. We found that based on the Rome IV criteria, alarm symptoms were of limited value in differentiating organic dyspepsia and organic upper GI diseases from functional dyspepsia. Age (odds ratio (OR) = 1.056, P = 0.012), smoking (OR = 4.714, P = 0.006) and anemia (OR = 88.270, P < 0.001) were independent predictors for organic upper GI diseases. For the comparison of epigastric pain syndrome, postprandial distress syndrome and epigastric pain syndrome combined with postprandial distress syndrome, the results showed that there were statistically significant differences in anorexia (P = 0.021) and previous visits (P = 0.012). The ClinicalTrials.gov number is NCT03479528. CONCLUSION: Most alarm symptoms had poor predictive value for organic dyspepsia and organic upper GI diseases based on Rome IV criteria. Gastroscopic screening should not be based solely on alarm symptoms.

Clinical Evaluation of Inflammatory and Blood Parameters in the Workup of Pediatric Chronic Abdominal Pain.

OBJECTIVE: To investigate the additional value of blood parameters (hemoglobin, C-reactive protein, erythrocyte sedimentation rate) to anti-tissue transglutaminase (anti-tTG), fecal calprotectin, and Giardia lamblia when discriminating a functional from an organic cause in the clinical evaluation of children with chronic abdominal pain. STUDY DESIGN: This retrospective cohort study included patients (4-18 years of age) with abdominal pain for >2 months. Data on hemoglobin, C-reactive protein, erythrocyte sedimentation rate, anti-tTG, fecal calprotectin, alarm symptoms, and diagnosis were collected. RESULTS: We identified 853 patients, of whom 102 (12%) had an organic disorder. Sensitivity and the area under the curve of strategy 1 (fecal calprotectin, anti-tTG, G lamblia, blood parameters) were 90% (95% CI, 83-95) and 0.87 (95% CI, 0.81-0.93), respectively, compared with 88% (95% CI, 81-93) and 0.85 (95% CI, 0.79-0.91), respectively, for strategy 2 (fecal calprotectin, anti-tTG, G lamblia) (P = NS). In the presence of ≥1 alarm symptoms, the sensitivity of strategies 1 and 2 was 92% (95% CI, 83-96) and 92% (95% CI, 83-96), and the areas under the curve were 0.93 (95% CI, 0.89-0.98) and 0.90 (95% CI, 0.84-0.97) (P = NS). CONCLUSIONS: To distinguish between a functional and an organic cause for chronic abdominal pain, hemoglobin, C-reactive protein, and erythrocyte sedimentation rate can be left out from the clinical evaluation as they might have no additional diagnostic yield. However, caution should be taken not to miss extraintestinal infections (2%).

Patient-initiated follow up affects fear of recurrence and healthcare use: a randomised trial in early-stage endometrial cancer.

OBJECTIVE: To test the hypothesis that patient-initiated follow up reduces the fear of cancer recurrence (FCR) and healthcare use when compared with traditional hospital-based follow up. DESIGN: Pragmatic, multicentre randomised trial. SETTING: Four Danish departments of gynaecology between May 2013 and May 2016. POPULATION: One hundred and fifty-six women diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage I low-intermediate risk endometrial carcinoma. METHODS: Women allocated to the control group attended hospital-based follow up consisting of regular outpatient visits for 3 years after primary treatment. Women in the intervention group were instructed in patient-initiated follow up, which included careful instruction in alarm symptoms and options for self-referral rather than a schedule of examinations. MAIN OUTCOME MEASURES: The primary end point was FCR as measured by the Fear of Cancer Recurrence Inventory (FCRI) after 10 months of follow up. Secondary end points included cancer-related use of primary and secondary health care during the first 10 months after treatment. RESULTS: In the primary analysis, FCR decreased significantly more in the control group from baseline to 10 months of follow up (difference -5.9, 95% CI -10.9 to -0.9). The majority of this improvement happened after only 3 months of follow up. Women receiving the intervention had fewer examinations at the department compared with the control group (0 versus 2 median visits, P < 0.01) and 58% of these examinations were scheduled because of vaginal bleeding. CONCLUSIONS: Hospital-based follow up alleviates FCR significantly more than patient-initiated follow up, though the estimated difference was small. Patient-initiated follow up is a feasible, potentially cost-reducing follow-up approach in a population of endometrial cancer survivors with low risk of recurrence. The decision to use patient-initiated follow up should balance these benefits and harms. TWEETABLE ABSTRACT: Patient-initiated follow up reduces healthcare use but maintains fear of recurrence in endometrial cancer. PLAIN LANGUAGE SUMMARY: Why and how was the study carried out? Follow up of women with endometrial cancer is resource consuming and previous research suggests that it is not effective. Even though the women benefit from reassurance at follow up, routine examinations may also remind the women of the disease and induce fear of cancer recurrence. Furthermore, routine follow up may delay recurrence diagnosis, because the women do not report their symptoms until the next scheduled visit. In the research explained in this article, patient-initiated follow up was evaluated as an alternative to traditional follow up. The women were randomly assigned to one of two follow-up programmes: regular gynaecological examinations at the department of gynaecology or self-referral with careful instruction in alarm symptoms, that is, patient-initiated follow up. The level of fear of cancer recurrence in the two groups was obtained by questionnaires. Information on healthcare use was obtained by questionnaires and a chart review. What were the main findings? Regular examinations at the department of gynaecology reduced the fear of cancer recurrence significantly more than patient-initiated follow up, though the difference was small. Women who were instructed in alarm symptoms, under self-referral, were able to monitor their symptoms, and this approach significantly reduced the number of examinations at the department of gynaecology. What are the limitations of the work? Participants in the self-referral group knew that they were examined less than other women, and this may have induced fear of cancer recurrence. Similarly, the regular completion of questionnaires regarding fear of cancer recurrence may have reminded the women of the disease and diminished the difference between the two groups. What are the implications for patients Patient-initiated follow up reduced healthcare use but maintained fear of cancer recurrence in women who had survived early-stage endometrial cancer. Future analyses on quality of life and cost-effectiveness are needed to balance the benefits and harms of patient-initiated follow up.

Combining Rome III criteria with alarm symptoms provides high specificity but low sensitivity for functional gastrointestinal disorders in children.

AIM: This study aimed to validate the Rome III criteria and alarm symptoms with regard to their ability to discriminate between organic and functional diagnoses in children with gastrointestinal complaints. METHODS: We recruited 258 children aged four years to 17 years who consulted a paediatrician in secondary or tertiary care in Stockholm from January 2013 to May 2014 due to gastrointestinal complaints. A symptom questionnaire based on the official Questionnaire on Pediatric Gastrointestinal Symptoms Rome III, including questions on alarm symptoms, was used. A diagnostic review of their medical records was also carried out. RESULTS: The reference diagnoses were organic (16%), pain-predominant functional gastrointestinal disorders (54%) and other functional diseases (30%). When the reported symptoms that fulfilled the Rome III criteria for pain-predominant functional gastrointestinal disorders were combined with an absence of alarm symptoms, they had a high specificity (0.90) for a functional diagnosis, but a low sensitivity (0.15). Alarm symptoms were equally common in patients with organic (83%) and functional diseases (80%, p = 0.66). CONCLUSIONS: Combining the Rome III criteria and an absence of alarm symptoms from patient questionnaires had high specificity but low sensitivity when diagnosing pain-predominant functional gastrointestinal disorders in children seeking medical care for gastrointestinal complaints.

Characteristics of 64 sarcoma patients referred to a sarcoma center after unplanned excision.

BACKGROUND AND METHODS: Unplanned excision of sarcoma before referral to specialist centers can affect prognosis and surgical outcome. The diagnostic pathway of these patients is uncertain and needs to be reviewed. We aimed to describe patient and tumor characteristics, initial symptoms, initial and final diagnosis, and explore reasons for unplanned excision in this patient group. From a previous study on 258 sarcoma patients, we identified 64 patients referred after surgery. Medical records were reviewed. RESULTS: The majority were soft tissue sarcomas, most often with thoracic location. Leiomyosarcoma was the most frequent final diagnosis, lipoma, and fibroma/dermatofibroma the most frequent initial diagnoses. Fifty percent were superficial small tumors, and 60.9% had not received diagnostic imaging before surgery. Fifty percent were referred from public surgical departments, and 1/3 from private specialists. Twenty-three patients had initial presence of alarm symptoms registered before surgery, the remaining 2/3 fell outside referral criteria or alarm symptoms were not discovered. CONCLUSIONS: Patients referred after unplanned excision often have small superficial tumors and the majority fall outside of defined referral criteria. Referral criteria are not a guarantee for detection of all sarcomas and surgeons should always be aware of the possibility of malignancy when removing a tumor.

Specific and non-specific symptoms of colorectal cancer and contact to general practice.

BACKGROUND: To improve survival rates for colorectal cancer, referral guidelines have been implemented. First step in the diagnostic process is for the individual to recognize the symptoms and contact his/her general practitioner (GP) for evaluation. OBJECTIVES: To determine (i) the prevalence of specific and non-specific symptom experiences indicative of colorectal cancer, (ii) the proportion of subsequent contacts to GPs, (iii) to explore the possible differences in symptom experience and contact to GPs between age and sex. METHODS: A nationwide study of 100000 adults, aged 20 years and older, were randomly selected in the general population and invited to participate in an internet-based survey. Items regarding experience of specific and non-specific alarm symptoms of colorectal cancer within the preceding 4 weeks and contact to GP were included. RESULTS: A total of 49706 subjects completed the questionnaire. Abdominal pain was the most common specific alarm symptom (19.7%) and tiredness was the most common non-specific symptom (49.8%). The experiences of symptoms were more common among women and more common in the youngest age groups for both sexes. The symptom leading to the highest proportion of GP contacts was rectal bleeding (33.8%). When experiencing any combination of two specific alarm symptoms, the proportion who contacted a GP was less than 50%. The combination of a non-specific and a specific alarm symptom gave rise to the highest proportion of GP contacts. CONCLUSION: Although specific and non-specific alarm symptoms of colorectal cancer are common in the general population, the proportion of GP contacts is low.

Help seeking for cancer 'alarm' symptoms: a qualitative interview study of primary care patients in the UK.

BACKGROUND: Delay in help seeking for cancer 'alarm' symptoms has been identified as a contributor to delayed diagnosis. AIM: To understand people's help-seeking decision making for cancer alarm symptoms, without imposing a cancer context. DESIGN AND SETTING: Community-based, qualitative interview study in the UK, using purposive sampling by sex, socioeconomic status, and prior help seeking, with framework analysis of transcripts. METHOD: Interviewees (n = 48) were recruited from a community-based sample (n = 1724) of adults aged ≥50 years who completed a health survey that included a list of symptoms. Cancer was not mentioned. Participants reporting any of 10 cancer alarm symptoms (n = 915) and who had consented to contact (n = 482) formed the potential pool from which people were invited to an interview focusing on their symptom experiences. RESULTS: Reasons for help seeking included symptom persistence, social influence, awareness/fear of a link with cancer, and 'just instinct'. Perceiving the symptom as trivial or 'normal' was a deterrent, as was stoicism, adopting self-management strategies, and fear of investigations. Negative attitudes to help seeking were common. Participants did not want to be seen as making a fuss, did not want to waste the doctor's time, and were sometimes not confident that the GP could help. CONCLUSION: Decision making about cancer alarm symptoms was complex. Recognition of cancer risk almost always motivated help seeking (more so than the fear of cancer being a deterrent), assisted by recent public-awareness campaigns. As well as symptom persistence motivating help seeking, it could also have the reverse effect. Negative attitudes to help seeking were significant deterrents.