The significance of the small adenoma: a longitudinal study of surveillance colonoscopy in an Australian population.

BACKGROUND: The international guidelines for surveillance following the finding of a small tubular adenoma vary between no surveillance or colonoscopy at 5 or 10 years, whereas surveillance after an advanced adenoma is 3 years. Optimization of surveillance reduces the risk of colorectal cancer (CRC) with efficient use of colonoscopy resources. We assessed the risks of advanced colorectal neoplasia following a baseline finding of a small adenoma compared with advanced adenoma. PATIENTS AND METHODS: A retrospective audit was undertaken of patients enrolled in a CRC surveillance program, wherein regular colonoscopies and screening with faecal immunochemical test (FIT) were provided. Patients diagnosed with either small or advanced adenoma followed by at least one surveillance colonoscopy were included. Advanced adenoma included adenomas with features of villous change, size of at least 10 mm, high-grade dysplasia, three or more small tubular adenomas and traditional and sessile serrated adenomas. Subdistribution hazard ratios were calculated for advanced neoplasia (CRC or advanced adenoma). RESULTS: Overall, 378 patients (62.6±11.2 years, 57.9% male) were included, with 44.2% diagnosed with small adenoma and 55.5% with advanced adenoma at baseline. The crude cumulative incidence of advanced neoplasia at first surveillance was 13.2 and 18.5% after small and advanced adenoma (P=0.16) (at 45.9 and 35.6 months, respectively), which became significant for advanced adenoma after adjustment (subdistribution hazard ratio=2.55, 95% confidence interval=1.49-4.35, P<001). A positive FIT was the only independent predictor of advanced neoplasia after a small adenoma at baseline colonoscopy (odds ratio=5.05, 95% confidence interval=1.27-20.02, P=0.02). CONCLUSIONS: The risk of advanced neoplasia following a small adenoma was lower than that following an advanced adenoma, but was strongly predicted by a positive FIT. Reducing frequency of colonoscopy while providing regular FIT might be a more efficient use of resources for this population.

Limited uptake of ulcerative colitis "treat-to-target" recommendations in real-world practice.

BACKGROUND AND AIMS: A "treat-to-target" approach has been proposed for ulcerative colitis (UC), with a target of combined clinical and endoscopic remission. The aim of the study was to evaluate the extent to which proposed targets are achieved in real-world care, along with clinician perceptions and potential challenges. METHODS: A multicentre, retrospective, cross-sectional review of patients with UC attending outpatient services in South Australia was conducted. Clinical and objective assessment of disease activity (endoscopy, histology, and/or biomarkers) was recorded. A survey evaluated gastroenterologists' perceptions of treat to target in UC. Statistical analysis included logistic regression and Fisher's exact tests. RESULTS: Of 246 patients with UC, 61% were in clinical remission (normal bowel habit and no rectal bleeding), 35% in clinical and endoscopic remission (Mayo endoscopic sub-score ≤ 1), and 16% in concordant clinical, endoscopic, and histological (Truelove and Richards' Index) remission. Rather than disease-related factors (extent/activity), clinician-related factors dominated outcome. Hospital location and the choice of therapy predicted combined clinical and endoscopic remission (OR 3.6, 95% CI 1.6-8.7, P < 0.001; OR 3.3, 95% CI 1.1-12.5, P = 0.04, respectively). Clinicians used C-reactive protein more often than endoscopy as a biomarker for disease activity (75% vs 47%, P < 0.001). In the survey, 45/61 gastroenterologists responded, with significant disparity between clinician estimates of targets achieved in practice and real-world data (P < 0.001 for clinical and endoscopic remission). CONCLUSIONS: Most patients with UC do not achieve composite clinical and endoscopic remission in "real-world" practice. Clinician uptake of proposed treat-to-target guidelines is a challenge to their implementation.

Diuretic-associated electrolyte disorders in the elderly: risk factors, impact, management and prevention.

Electrolyte and acid-base disorders are commonly encountered adverse effects of various diuretic agents, which are associated with considerable morbidity and mortality especially in elderly patients. Diuretic use is associated with hyponatraemia, hypernatraemia, hypokalaemia, hyperkalaemia, hyperuricaemia and alterations in magnesium, calcium, phosphate and acid-base homeostasis. Clinical studies have provided important data on the relative frequency and risk factors for these diuretic-associated electrolyte and acid-base disorders. Old age is one of the most recognized risk factors for diuretic-associated electrolyte and acid-base disorders. Hyponatraemia and hypokalaemia are the most common electrolyte abnormalities found among the elderly population taking diuretics. Both conditions are associated with short and long-term morbidity as well as mortality. This article presents an overview of the literature on diuretic-associated electrolyte disorders and suggested risk factors for their development especially in elderly patients when evidence is available. The impact of these electrolyte disorders on patients will be discussed. Strategies to prevent adverse outcomes related to these disorders should involve careful consideration of risk factors as well as ongoing clinical and laboratory evaluations in the course of using these diuretics.

Rhabdomyolysis in acute primary adrenal insufficiency complicated by severe hyponatraemia.

Patients with acute adrenal insufficiency may have musculoskeletal symptoms including flexion contractures, myopathy and hyperkalaemic neuromyopathy. However, the association between rhabdomyolysis and acute adrenal insufficiency is extremely rare and has only been reported infrequently in the literature. Hyponatraemia is often present in association with acute adrenal insufficiency complicated by rhabdomyolysis. We herein report the case of a patient with acute primary adrenal insufficiency and severe hyponatraemia complicated by rhabdomyolysis and acute kidney injury.

Medication prescription among elderly patients admitted through an acute assessment unit.

AIM: This study assessed medication use patterns and polypharmacy in patients who were admitted through an acute assessment unit (AAU) and stratified results according to patient age. This study also examined risk factors associated with polypharmacy and consequences of polypharmacy, namely prescription writing errors, drug-drug interaction and geriatric syndrome. METHODS: The medication charts and admission notes of 200 consecutive patients admitted through the AAU over a period of 1 month were retrospectively reviewed. Data were collected on patients' demographics, comorbidities, types and number of medications, hospital length of stay and reason(s) for presentation. Potentially harmful prescription errors or errors necessitating intervention were also recorded, as were any potential adverse drug-drug interactions. RESULTS: Medications for the treatment of disorders of the cardiovascular (46% of total patients) and nervous systems (30%) predominated. Of the 200 patients reviewed, 158 were aged ≥ 65 years and their mean serum creatinine was higher than those aged < 65 years (100.9 ± 54.0 vs. 79.9 ± 45.9 µmol/L, P = 0.01), 81% were taking five or more concurrent regular medications at the time of admission. Of all 200 patients, 28% suffered renal impairment, defined as creatinine > 100 µmol/L for women and > 120 µmol/L for men. The presence of more than two comorbidities (odds ratio (OR) 6.80; 95% confidence interval (CI) 2.89-16.00; P < 0.001) and age (OR 2.91; 95% CI 1.24-6.80; P = 0.01), were factors associated with polypharmacy. Excessive polypharmacy was associated with an increased risk of prescription errors that could cause temporary harm or required intervention (OR 5.23; 95% CI 1.39, 19.69; P = 0.009) but was not associated with a prolonged length of stay. CONCLUSIONS: This study showed that polypharmacy and renal impairment are prevalent amongst elderly patients admitted through an AAU. Polypharmacy in the elderly is attributable to greater comorbidities and is associated with an increased risk of adverse consequences. To avoid inappropriate medication use and improve the quality of prescription among those with polypharmacy, careful review of elderly patients' drugs is needed while they are in the AAU.

Streptococcus dysgalactiae endocarditis presenting as acute endophthalmitis.

Endogenous endophthalmitis is a rare ocular infection affecting the vitreous and/or aqueous humours. It is associated with poor visual prognosis and its commonest endogenous aetiology is infective endocarditis. The causative organisms of endogenous endophthalmitis complicating endocarditis are mainly Group A or B streptococci. The identification of Group C and G streptococci such as Streptococcus dysgalactiae is comparatively uncommon and has only been reported in a few case reports or series. We therefore report a case of infective endocarditis caused by Streptococcus dysgalactiae first presenting with endogenous endophthalmitis, the most likely source being osteomyelitis of both feet in a patient with type I diabetes. The patient was treated with a course of intravenous benzylpenicillin, intravitreal antibiotics, bilateral below knee amputations and mitral valve replacement. She survived all surgical procedures and regained partial visual acuity in the affected eye.

Severe hyponatremia and other electrolyte disturbances associated with indapamide.

PURPOSE: The aim of this study is to evaluate patients' demographics, patterns of presentation and outcomes of admissions with severe hyponatremia and other electrolyte disturbances that are related to indapamide. METHODS: Patients with severe indapamide-related hyponatremia (defined as serum sodium <125 mmol/L) admitted to the Department of General Medicine of a tertiary teaching hospital between 1 July 2006 and 30 June 2009 were evaluated in this study. Patients' characteristics, clinical features of their presentation and other electrolyte disturbances were analyzed retrospectively. RESULTS: Eleven patients were admitted with severe hyponatremia and other electrolyte disturbances associated with indapamide use. All patients were female and elderly (age: 81.7 ± 5.8 years). Their mean weight was 59.0 ± 8.8 kg. Indapamide sustained release (SR) 1.5 mg daily was taken by eight of eleven patients and the others took indapamide 2.5 mg in combination with perindopril. The mean serum sodium concentration on presentation was 110.9 ± 5.9 mmol/L and was associated with findings of hypokalemia in ten patients and hypomagnesemia in eight patients. All patients presented predominantly with neurological manifestations, delirium (six patients) being the most common. Electrocardiographic changes were common (nine patients) including prolonged QT interval in six patients. All the patients' electrolyte abnormalities were corrected without any life-threatening complications. CONCLUSIONS: This study highlights that the use of indapamide is associated with severe hyponatremia and other electrolyte disturbances. Therefore clinicians should be aware of severe electrolyte disturbances arising from indapamide. New onset of neurological symptoms such as delirium and unsteady gait in the elderly taking indapamide should prompt evaluation of their electrolyte profile.