Asia Pacific consensus recommendations for colorectal cancer screening.

Colorectal cancer (CRC) is rapidly increasing in Asia, but screening guidelines are lacking. Through reviewing the literature and regional data, and using the modified Delphi process, the Asia Pacific Working Group on Colorectal Cancer and international experts launch consensus recommendations aiming to improve the awareness of healthcare providers of the changing epidemiology and screening tests available. The incidence, anatomical distribution and mortality of CRC among Asian populations are not different compared with Western countries. There is a trend of proximal migration of colonic polyps. Flat or depressed lesions are not uncommon. Screening for CRC should be started at the age of 50 years. Male gender, smoking, obesity and family history are risk factors for colorectal neoplasia. Faecal occult blood test (FOBT, guaiac-based and immunochemical tests), flexible sigmoidoscopy and colonoscopy are recommended for CRC screening. Double-contrast barium enema and CT colonography are not preferred. In resource-limited countries, FOBT is the first choice for CRC screening. Polyps 5-9 mm in diameter should be removed endoscopically and, following a negative colonoscopy, a repeat examination should be performed in 10 years. Screening for CRC should be a national health priority in most Asian countries. Studies on barriers to CRC screening, education for the public and engagement of primary care physicians should be undertaken. There is no consensus on whether nurses should be trained to perform endoscopic procedures for screening of colorectal neoplasia.

Risk factors for cardiopulmonary events during propofol-mediated upper endoscopy and colonoscopy.

BACKGROUND: Propofol-mediated sedation for endoscopy is popular because of its rapid onset and recovery profile. AIM: To examine procedure-specific occurrence and risk factors for cardiopulmonary events during propofol-mediated upper endoscopy (EGD) and colonoscopy. DESIGN: A cohort study using the Clinical Outcomes Research Initiative database was used to determine the frequency of cardiopulmonary events. Clinical Outcomes Research Initiative consisted of 69 practice sites comprising 593 US endoscopists. Multivariate logistic regression analysis used variables, such as age, ASA classification and propofol administration by monitored anaesthesia care or gastroenterologist-administered propofol to determine the risk of cardiopulmonary events. RESULTS: The overall cardiopulmonary event rate for 5928 EGDs and 11 683 colonoscopies was 11.7/1000 cases. For colonoscopy, ascending ASA classification was associated with an increased risk. Monitored anaesthesia care was associated with a decreased adjusted relative risk (0.5, 95% CI: 0.36-0.72). ASA I and II patients receiving monitored anaesthesia care for EGD exhibited a significantly lower relative risk (ARR 0.29, 95% CI: 0.14-0.64). For subjects with ASA class III or greater, there was no difference in the risk between monitored anaesthesia care and gastroenterologist-administered propofol. CONCLUSIONS: There are procedure-specific risk factors for cardiopulmonary events during propofol-mediated EGD and colonoscopy. These should be taken into account during future prospective comparative trials.

Variation in practice of ileal intubation among diverse endoscopy settings: results from a national endoscopic database.

BACKGROUND: Terminal ileum intubation rates at colonoscopy are variable. One of the major indications for terminal ileum intubation is to identify Crohn's disease. Signs and symptoms which raise a suspicion of Crohn's include abdominal pain/bloating, anaemia and diarrhoea. AIM: To determine the proportion of terminal ileal intubation in patients undergoing evaluation of abdominal pain/bloating, anaemia or diarrhoea with normal endoscopic findings at colonoscopy. METHODS: The Clinical Outcomes Research Initiative national endoscopic database was analysed to determine the proportion of terminal ileum intubation in patients undergoing evaluation of either abdominal pain/bloating, anaemia or diarrhoea with normal endoscopic findings at colonoscopy and to characterize this population of patients. Patients with known or suspected inflammatory bowel disease were excluded from the analysis. RESULTS: Between January 2000 and December 2003, 21 638 patients underwent complete colonoscopy for evaluation of either abdominal pain/bloating, anaemia or diarrhoea with normal colon findings. Overall, 3858 patients (18%) underwent terminal ileum evaluation. Intubation rates differed according to procedure indication: abdominal pain (13%), anaemia (13%), diarrhoea (28%). Terminal ileum assessment declined with advancing patient age and was least frequent in Black patients (12% vs. 18% in non-Blacks, P < 0.0001). Ileal intubation rates also varied among endoscopy site types: community (17%), academic (21%), Veterans Affairs Medical Centres (17%), P < 0.0001. Multiple logistic regression identified patients with the indication of diarrhoea (OR: 2.58) as more likely to undergo terminal ileum intubation when compared with those with abdominal pain/bloating. Patients in Veterans Affairs (OR: 1.26) and academic (OR: 1.29) sites were more likely to undergo terminal ileum intubation compared with community sites. CONCLUSION: Less than one-fifth of patients with either abdominal pain/bloating, anaemia or diarrhoea underwent ileal intubation in the setting of a normal colonoscopy. Significant practice variation was observed in rates of terminal ileum evaluation. Further study is required to determine whether terminal ileum examination impacts patient management or outcome.

Review article: balancing the ideal versus the practical-considerations of colorectal cancer prevention and screening.

Colorectal cancer is responsible for over 500 000 deaths annually world-wide. Death from colorectal cancer is preventable, primarily through early diagnosis of disease that has not metastasized. The disease itself may be prevented by the detection and removal of colorectal adenomas, from which more than 95% of colorectal cancers arise. Currently there are several screening methods for the disease. These include faecal occult blood tests, sigmoidoscopy, barium enema and colonscopy as well as emerging methods of virtual colonoscopy and faecal DNA testing. While direct and indirect evidence support the efficacy of these tests they differ from each other in their sensitivity, specificity, cost, and safety. Various professional organizations in different geographical regions of the world have published recommendations on which screening methods to use and when in patients at average- or high-risk. The challenge in reducing the incidence and mortality of this disease lies in increasing accessibility to and compliance with screening and delivery within a quality assured programme.

One-time screening for colorectal cancer with combined fecal occult-blood testing and examination of the distal colon.

BACKGROUND: Fecal occult-blood testing and sigmoidoscopy have been recommended for screening for colorectal cancer, but the sensitivity of such combined testing for detecting neoplasia is uncertain. At 13 Veterans Affairs medical centers, we performed colonoscopy to determine the prevalence of neoplasia and the sensitivity of one-time screening with a fecal occult-blood test plus sigmoidoscopy. METHODS: Asymptomatic subjects (age range, 50 to 75 years) provided stool specimens on cards from three consecutive days for fecal occult-blood testing, which were rehydrated for interpretation. They then underwent colonoscopy. Sigmoidoscopy was defined in this study as examination of the rectum and sigmoid colon during colonoscopy, and sensitivity was estimated by determining how many patients with advanced neoplasia had an adenoma in the rectum or sigmoid colon. Advanced colonic neoplasia was defined as an adenoma 10 mm or more in diameter, a villous adenoma, an adenoma with high-grade dysplasia, or invasive cancer. Classification of subjects according to the findings was based on the most advanced lesion. RESULTS: A total of 2885 subjects returned the three specimen cards for fecal occult-blood testing and underwent a complete colonoscopic examination. A total of 23.9 percent of subjects with advanced neoplasia had a positive test for fecal occult blood. As compared with subjects who had a negative test for fecal occult blood, the relative risk of advanced neoplasia in subjects who had a positive test was 3.47 (95 percent confidence interval, 2.76 to 4.35). Sigmoidoscopy identified 70.3 percent of all subjects with advanced neoplasia. Combined one-time screening with a fecal occult-blood test and sigmoidoscopy identified 75.8 percent of subjects with advanced neoplasia. CONCLUSIONS: One-time screening with both a fecal occult-blood test with rehydration and sigmoidoscopy fails to detect advanced colonic neoplasia in 24 percent of subjects with the condition.

Pathological documentation of complete elimination of Barrett's metaplasia following endoscopic multipolar electrocoagulation therapy.

The previous paradigm that Barrett's is an irreversible premalignant lesion has recently been challenged by a proliferation of reports documenting elimination of Barrett's by a variety of endoscopic techniques. Whether Barrett's is entirely eliminated is unknown as endoscopic biopsy samples the surface of the epithelium only. Numerous reports document underlying specialised columnar epithelium in many of these trials. Until now there have been no reports of pathological examination of the entire oesophagus as a specimen. This case documents complete elimination of intestinal metaplasia from the oesophagus and supports the biological plausibility of these research techniques.

Management of chronic pediatric diseases with interactive health games: theory and research findings.

In randomized clinical trials, children and adolescents improved their self care and reduced their emergency clinical utilization after playing health education and disease management video games. A diabetes game reduced diabetes-related urgent and emergency visits by 77 percent after diabetic youngsters had the game at home for six months, compared to no reduction in clinical utilization in a control group of diabetic youngsters who took home an entertainment video game that had no health content. Positive impacts were also found in clinical trials of games for asthma self-management and smoking prevention.

How far to go? Screening and surveillance in Barrett's esophagus.

There is no dispute that Barrett's esophagus (BE) is associated with an increased risk of esophageal adenocarcinoma. Detecting these cancers early can improve patient survival. But should screening be used to detect BE, or should a surveillance program monitor those already diagnosed with BE for neoplastic changes? Endoscopy and endoscopic biopsy are the only tools available for such screening and surveillance, and the cost effectiveness of either approach must be considered. Two possible solutions are discussed. First, screening could be limited to patients considered at high risk for BE and associated adenocarcinoma. With this approach, more precise risk stratification would be required. The second possible approach is to combine screening for high-risk patients and surveillance for those already diagnosed with BE. Additional outcomes data are needed to determine how often and for what length of time endoscopic surveillance should continue in a patient after several examinations are negative for adenocarcinoma.

The effects of grades on course enjoyment: did you get the grade you wanted?

BACKGROUND: Students tend to rate university courses more positively if they do well. Greenwald and Gillmore (1997a) suggested that it is not students' absolute grades that are important but rather how these grades compare to their expectations. However, this hypothesis is difficult to evaluate because few studies have measured grade expectations at the beginning of courses. AIM: By measuring students' grade expectations and enjoyment at several stages during a course, we hoped to evaluate the extent to which expectations modulate the impact of grades on course enjoyment. SAMPLE: Participants were 242 students in a university course in psychology. METHOD: Students were asked what grades they expected, and how much they were enjoying the course, at four stages. The effect of grades and grade expectations on enjoyment were analysed using restricted maximum likelihood (REML) and regression analyses. RESULTS: The best predictor of course enjoyment varied somewhat at different stages, but in general it was the extent to which students' grades surpassed their expectations. Students' expectations at the beginning of the course proved particularly influential. CONCLUSIONS: Grade expectations do influence how students react to course grades, but the prominent role of pre-course expectations suggests that it may be important to distinguish between grade aspirations and grade expectations. It appears to be students' aspirations--the grades they hope to achieve--that most strongly shape their emotional reactions, rather than the more realistic expectations they may form later in a course.

Use of colonoscopy to screen asymptomatic adults for colorectal cancer. Veterans Affairs Cooperative Study Group 380.

BACKGROUND AND METHODS: The role of colonoscopy in screening for colorectal cancer is uncertain. At 13 Veterans Affairs Medical Centers, we performed colonoscopy to determine the prevalence and location of advanced colonic neoplasms and the risk of advanced proximal neoplasia in asymptomatic patients (age range, 50 to 75 years) with or without distal neoplasia. Advanced colonic neoplasia was defined as an adenoma that was 10 mm or more in diameter, a villous adenoma, an adenoma with high-grade dysplasia, or invasive cancer. In patients with more than one neoplastic lesion, classification was based on the most advanced lesion. RESULTS: Of 17,732 patients screened for enrollment, 3196 were enrolled; 3121 of the enrolled patients (97.7 percent) underwent complete examination of the colon. The mean age of the patients was 62.9 years, and 96.8 percent were men. Colonoscopic examination showed one or more neoplastic lesions in 37.5 percent of the patients, an adenoma with a diameter of at least 10 mm or a villous adenoma in 7.9 percent, an adenoma with high-grade dysplasia in 1.6 percent, and invasive cancer in 1.0 percent. Of the 1765 patients with no polyps in the portion of the colon that was distal to the splenic flexure, 48 (2.7 percent) had advanced proximal neoplasms. Patients with large adenomas (> or = 10 mm) or small adenomas (< 10 mm) in the distal colon were more likely to have advanced proximal neoplasia than were patients with no distal adenomas (odds ratios, 3.4 [95 percent confidence interval, 1.8 to 6.5] and 2.6 (95 percent confidence interval, 1.7 to 4.1], respectively). However, 52 percent of the 128 patients with advanced proximal neoplasia had no distal adenomas. CONCLUSIONS: Colonoscopic screening can detect advanced colonic neoplasms in asymptomatic adults. Many of these neoplasms would not be detected with sigmoidoscopy.

Noninvasive tests as a substitute for histology in the diagnosis of Helicobacter pylori infection.

BACKGROUND: Rapid urease tests for Helicobacter pylori have a sensitivity of 80% to 90%. Therefore histologic examination of gastric biopsies is recommended as a "backup" diagnostic test in rapid urease test-negative patients. However, noninvasive tests (urea breath test, serology, whole blood antibody tests) may provide a more rapid diagnosis and be less expensive but offer similar accuracy. METHODS: Sixty-seven patients (no prior treatment for H pylori, no proton pump inhibitors, antibiotics, or bismuth within 4 weeks) undergoing endoscopy for evaluation of dyspepsia symptoms and testing rapid urease test-negative by antral biopsy were enrolled. All had the following tests: gastric biopsies (2 antral, 1 fundus; H&E and Alcian Yellow stain) examined for gastritis and H pylori; (13)C-UBT; capillary blood for whole blood rapid antibody tests: FlexSure HP, QuickVue, AccuStat, and Stat-Simple Pylori; serum for FlexSure HP; HM-CAP enzyme-linked immunoassay. H pylori infection was diagnosed (reference standard) if chronic gastritis was present on histology and at least 2 of the 3 following tests were positive: urea breath test, H pylori organisms unequivocally demonstrated in biopsies on special stain, and/or enzyme-linked immunoassay. The test and treatment costs per patient were calculated. RESULTS: Of 67 patients with a negative rapid urease test, 4 were positive for H pylori. None had active peptic ulcer disease. Histology only identified 1 patient with organisms visible on special stain. Using chronic active gastritis (neutrophilic and mononuclear infiltrate) as a diagnostic criterion for H pylori, 6 patients would have been judged positive. However, only 2 of these were truly positive by the reference standard (positive predictive value 33%). Negative predictive value for presence of organisms and chronic active gastritis was 95% and 97%, respectively. All of the noninvasive tests identified all 4 truly positive patients correctly. Urea breath test and FlexSure whole blood assay yielded a substantial number of false-positive results (positive predictive value 31% and 36%, respectively); positive predictive value for the other tests ranged from 50% to 80%. All tests except histology had a negative predictive value of 100%. Histology was the most costly test (p < 0. 001 compared with all other tests), followed by urea breath test and HM-CAP serology (p < 0.001 compared with all rapid antibody tests). CONCLUSIONS: Whole blood or serum antibody testing is a rapid, accurate, and cost-effective means for establishing H pylori status in rapid urease test-negative patients. Whole blood or serology rapid antibody testing should substitute for histology when the patient has not been previously treated for H pylori.

Colonic neoplasia in patients with nonspecific GI symptoms.

BACKGROUND: The purpose of this study was to determine the prevalence rate of colonic polyps or masses 1 cm or greater in diameter in patients with nonspecific abdominal symptoms, from diverse practice settings, using a national endoscopic database. METHODS: Consecutive patients undergoing colonoscopy were included based on procedure indication. Endoscopic data were generated with a computer database at each practice site, transmitted to a central data bank and merged with data from multiple sites for analysis. Group 1 patients had nonspecific abdominal symptoms, which were defined as pain, constipation and diarrhea. Group 2 patients had a positive fecal occult blood test. Group 3 patients were asymptomatic, undergoing screening colonoscopy. Serious colon pathology was defined as a polyp or mass greater than 9 mm in size. RESULTS: Data were collected from 31 practice sites in 21 states during a period of 18 months. Of the 20,745 colonoscopy examinations, 9.2% were performed to evaluate patients with nonspecific abdominal symptoms, excluding other indications. Among patients with nonspecific symptoms 7.27% had polyp(s) 1 cm or greater in diameter compared with 17.05% of patients with positive fecal occult blood test (odds ratio 2.12: CI [1.73, 2.60]; p < 0.001). Patients with nonspecific symptoms had similar rates of large polyps as asymptomatic patients (7.27% vs. 6.45%, p = 0.32). Multivariate analysis identified several independent variables including increasing age, male gender and practice site at a Veterans Affairs Medical Center. CONCLUSIONS: In diverse, practice-based settings, patients with nonspecific abdominal symptoms who are referred for colonoscopy do not have a higher risk of serious colonic pathology than asymptomatic patients.

Patterns of endoscopy use in the United States.

BACKGROUND & AIMS: The aim of this study was to use a large national endoscopic database to determine why routine endoscopy is performed in diverse practice settings. METHODS: A computerized endoscopic report generator was developed and disseminated to gastrointestinal (GI) specialists in diverse practice settings. After reports were generated, a data file was transmitted electronically to a central databank, where data were merged from multiple sites for analysis. RESULTS: From April 1, 1997, to October 28, 1998, 276 physicians in 31 practice sites in 21 states provided 18,444 esophagogastroduodenoscopy (EGD) reports, 20,748 colonoscopy reports, and 9767 flexible sigmoidoscopy reports to the central databank. EGD was most commonly performed to evaluate dyspepsia and/or abdominal pain (23.7%), dysphagia (20%), symptoms of gastroesophageal reflux without dysphagia (17%), and suspected upper GI bleeding (16.3%). Colonoscopy was most often performed for surveillance of prior neoplasia (24%) and evaluation of hematochezia (19%) or positive fecal occult blood test (15%). Flexible sigmoidoscopy was most commonly performed for routine screening (40%) and evaluation of hematochezia (22%). There were significant differences between academic and nonacademic sites. CONCLUSIONS: The endoscopic database can be an important resource for future research in endoscopy by documenting current practice patterns and changes in practice over time.

Evaluation of rapid antibody tests for the diagnosis of Helicobacter pylori infection.

OBJECTIVE: The aim of this study was to compare the performance characteristics of one serum and four whole blood rapid antibody tests for Helicobacter pylori infection. METHODS: A total of 97 outpatients referred for endoscopic evaluation of dyspepsia were included. Antral biopsies were obtained for histology and rapid urease test. Serum was tested with an enzyme-linked immunoassay (HM-CAP) and a rapid serology test (FlexSure HP). A commercially available 13C-urea breath test was performed. Capillary blood obtained by fingerstick was tested with FlexSure HP, QuickVue, Accustat, and StatSimple pylori tests. Sensitivity, specificity, and accuracy of each rapid test was calculated relative to a criterion standard of histological gastritis and at least two of the four following tests positive: identifiable organisms on specially stained slides, rapid urease test, urea breath test, or serum immunoassay. RESULTS: A total of 30 patients (31%) were infected. The FlexSure HP Serum, and FlexSure HP, QuickVue, Accustat, and StatSimple pylori whole blood tests had sensitivities of 90%, 87%, 83%, 76%, and 90%; specificities of 94%, 90%, 96%, 96%, and 98%, and accuracies of 93%, 88%, 92%, 87%, and 96%, respectively. Sensitivities were not statistically different. StatSimple pylori was more specific than FlexSure HP whole blood (p<0.03), and more accurate than FlexSure whole blood (p<0.024) and Accustat (p< 0.01). Serum immunoassay was significantly more sensitive (97%) than FlexSure whole blood, QuickVue, and Accustat (p<0.01), but its specificity (95%) was not statistically different from the rapid tests. CONCLUSION: Rapid antibody testing provides an accurate diagnosis of H. pylori infection. In general, these tests are less sensitive than, but as specific as, standard serology.

Effectiveness of Helicobacter pylori therapies in a clinical practice setting.

BACKGROUND: Whether eradication rates for Helicobacter pylori treatment regimens obtained in controlled clinical trials (efficacy) can also be obtained in clinical practice (effectiveness) is unknown because no such trials have been reported in the United States. OBJECTIVES: To determine the eradication rates of H pylori in a community practice setting and the effects of practice variation in the choice of treatment regimen on patient outcome (H pylori infection cure) and cost. METHODS: Between February 1 and December 30, 1996, 38 community-based gastroenterologists in the Portland, Ore, metropolitan area enrolled a total of 250 patients infected with H pylori, as determined by endoscopic or noninvasive methods. Various therapeutic regimens aimed at eradicating H pylori were used by the gastroenterologists, and a posttreatment urea breath test was used to determine H pylori infection cure. Compliance and incidental effects were also measured and decision analysis was used to estimate the cost of treatment. RESULTS: The regimens used varied considerably. Patients receiving a 2- or 3-times-a-day treatment regimen were significantly more compliant (P=.01) than those receiving a 4-times-a-day regimen. Proton pump inhibitor-based triple-therapy regimens were significantly more effective than all other treatment regimens combined (87% vs 70%; P = .001) in eradicating H pylori. These proton pump inhibitor-based triple-therapy regimens were also more cost-effective by decision analysis for a hypothetical cohort of patients with duodenal ulcer disease. CONCLUSIONS: The considerable variation in the choice of treatment regimens affects the clinical and economic outcomes of patients undergoing therapy for H pylori infection. Whether these data reflect the outcome in other communities is unknown but should be determined. It will be necessary to determine if the dissemination of these data results in a reduction of practice variation and improvement in clinical and economic outcomes of patients being treated for H pylori infection in clinical practice.

Reinforcement without awareness: I. Voice level.

Although some studies have reported that reinforcement can strengthen people's behaviour without their awareness, most studies that have incorporated adequate procedures for assessing awareness have been unsuccessful. Using rigorous procedures, we report two studies designed to provide more scope for learning without awareness by making the reinforcement contingency as unobtrusive as possible. Subjects were told that the experiment was on ESP, and that they were to say which of two words the experimenter was thinking about. In fact, reinforcement was contingent on the loudness of the subject's voice when responding. Even though subjects reported no awareness of a relationship between trial outcomes and their behaviour, the probability of the reinforced responses increased significantly over trials in both experiments. These results support the view that reinforcement can occur without awareness.

Reinforcement without awareness: II. Word class.

In a previous study of reinforcement without awareness by Lieberman, Sunnucks, & Kirk (this issue), subjects were told that the experiment was on ESP; two words were presented on every trial, and their task was to choose the word the experimenter was thinking of. In fact, reinforcement was contingent on the loudness of the subjects' voices when responding. They found stronger evidence for reinforcement without awareness than in many previous studies, and they attributed their success in part to the reinforcement of a response to which subjects were unlikely to attend. To explore this factor further, we again used an ESP cover story but reinforced subjects for choosing the word in each pair that contained a double letter. We found evidence of reinforcement without awareness in three experiments and also identified two factors that influence these effects: Learning did not occur if subjects (a) were encouraged to test irrelevant hypotheses, or (b) sat in an uncomfortable chair. We speculate that learning without awareness may be more likely when subjects are relaxed and that hypothesis testing and uncomfortable chairs impair such learning because they prevent relaxation.