Alaa Rostom

Prevalence of Adenomas and Colorectal Cancer in Average Risk Individuals: A Systematic Review and Meta-analysis

BACKGROUND & AIMSnThere is an extensive yet inconsistent body of literature reporting on the prevalence of adenomatous polyps (adenomas) and colorectal cancer among average risk individuals. The objectives of our study were to determine the pooled prevalence of adenomas and colorectal cancer, as well as nonadvanced and advanced adenomas, among average risk North Americans.nnnMETHODSnArticles were obtained by searching electronic databases (MEDLINE: 1950 through March 2008 and EMBASE: 1980 through March 2008), bibliographies, major journals, and conference proceedings, with no language restrictions. Two reviewers independently selected cross-sectional studies reporting adenoma and colorectal cancer prevalence rates in average risk individuals and assessed studies for inclusion and quality, and extracted the data for analysis. Pooled adenoma and colorectal cancer prevalence rates were estimated using fixed and random effects models. Stratification and metaregression was used to assess heterogeneity.nnnRESULTSnBased on 18 included studies, the pooled prevalence of adenomas, colorectal cancer, nonadvanced adenomas, and advanced adenomas was 30.2%, 0.3%, 17.7%, and 5.7%, respectively. Heterogeneity was observed in the pooled prevalence rates for overall adenomas, advanced adenomas, and colorectal cancer and was explained by the mean age (> or = 65 years vs < 65 years) with older cohorts reporting higher prevalence rates. None of the study quality indicators was found to be significant predictors of heterogeneity.nnnCONCLUSIONSnThe high prevalence of advanced adenomas and colorectal cancer, especially among older screen-eligible individuals, provides impetus for expanding colorectal cancer screening programs. Furthermore, the pooled prevalence estimates can be used as quality indicators for established programs.

COX-2 Selective Inhibitors in the Treatment of Osteoarthritis

OBJECTIVESnTo assess the efficacy of cyclooxygenase-2 selective inhibitors (coxibs) in osteoarthritis (OA) and their gastrointestinal, cardiovascular, renovascular, and hepatic side effects compared with traditional nonsteroidal antiinflammatory drugs (NSAIDs) and acetaminophen.nnnMETHODSnBibliographic database searches for randomized controlled trials, meta-analyses, and literature reviews.nnnRESULTSnCoxibs are comparable to traditional NSAIDs, providing moderate benefit for OA patients in pain and function versus placebo. NSAIDs, including coxibs, are superior to acetaminophen for OA, particularly in patients with moderate to severe pain. Coxibs decrease gastroduodenal ulcers (74% relative risk reduction) and ulcer complications (61% reduction) versus traditional NSAIDs. Meta-analysis of randomized trials indicates that coxibs increase the risk of myocardial infarctions approximately twofold versus placebo and versus naproxen, but do not increase the risk versus nonnaproxen NSAIDs. NSAIDs, including coxibs, commonly cause fluid retention and increase blood pressure and uncommonly induce congestive heart failure or significant renal dysfunction; risk factors include advanced age, hypertension, and heart or kidney disease. NSAIDs are a rare cause of clinical hepatotoxicity (<1 liver-related death per 100,000 NSAID users in clinical studies). Increased rates of aminotransferase elevations occur with rofecoxib (2%) and high-dose lumiracoxib (3%), and postmarketing cases of clinical liver injury with lumiracoxib have been reported recently.nnnCONCLUSIONSnCoxibs are as effective as traditional NSAIDs and superior to acetaminophen for the treatment of OA. Coxibs cause fewer gastrointestinal complications than traditional NSAIDs. Coxibs increase cardiovascular risk versus placebo and naproxen-but probably not versus nonnaproxen NSAIDs. Blood pressure commonly increases after initiation of selective or nonselective NSAIDs, especially in hypertensive patients.

Evidence of Endothelial Dysfunction in Patients With Inflammatory Bowel Disease

BACKGROUND & AIMSnChronic inflammation has a major role in the development and propagation of endothelial dysfunction, which can lead to coronary artery disease. Endothelial dysfunction has been described in patients with various and diverse chronic inflammatory conditions. Altered vascular flow has been proposed to mediate inflammation in inflammatory bowel disease (IBD), although the role of endothelial dysfunction remains obscure. The purpose of our study was to assess endothelial function in patients with IBD.nnnMETHODSnNinety-eight subjects were included in this study; 48 with IBD (17 with ulcerative colitis and 31 with Crohns disease) and 50 healthy controls. Endothelial function was assessed by pulse arterial tonometry (PAT) and brachial ultrasound to determine flow-mediated dilation and shear stress reactive hyperemia. The impact of disease activity, disease duration, and IBD therapy also was assessed.nnnRESULTSnBaseline demographic characteristics, including cardiovascular risk factors, were similar in all groups. IBD patients showed microvascular endothelial dysfunction, with lower PAT indices (P < .01) and shear stress reactive hyperemia (P < .05) compared with controls. There was no relationship between microvascular endothelial dysfunction, disease duration, underlying therapy, or clinical disease activity. There was a positive association between lower PAT scores and recent abdominal pain (P < .05).nnnCONCLUSIONSnThis was a large study assessing endothelial dysfunction in IBD. Both ulcerative colitis and Crohns disease patients showed evidence of microvascular endothelial dysfunction. Future research could determine whether endothelial dysfunction is involved in the pathogenesis of IBD or increases the risk of cardiovascular events in this patient population.

Methodology for Randomized Trials of Patients With Nonvariceal Upper Gastrointestinal Bleeding: Recommendations From an International Consensus Conference

The aim of this document is to provide a methodological framework for the design, performance, analysis, interpretation, and communication of randomized trials that assess management of patients with nonvariceal upper gastrointestinal bleeding. Literature searches were performed and an iterative process with electronic and face-to-face meetings was used to achieve consensus among panel members as part of an International Consensus Conference on Nonvariceal Upper Gastrointestinal Bleeding. Recommendations of the panel include the following. Randomized trials must explicitly state their primary hypothesis. A nonmanipulable randomization schedule with concealed allocation should be used. Stratification (e.g., for age and stigmata of hemorrhage) may be considered, especially in smaller studies. The patient and personnel providing care or recording information should be blinded. Inclusion criteria should be overt bleeding with endoscopy performed within 24u2009h or less. One type of lesion (e.g., ulcer) should be studied with stigmata to be included predefined. Use of placebo/no therapy vs. active controls depends on current standard practice. Standardizing study and key non-study interventions should ensure uniform provision of interventions. Criteria for repeat endoscopy and subsequent interventions should be predefined. The primary end point should be further bleeding (persistent and recurrent bleeding) with primary assessment at 7 days; mortality, with primary assessment at 30 days, would be appropriate in very large trials. Sample size calculation based on assumptions regarding primary end point results with regard to study intervention and control must be provided, and all patients enrolled must be accounted for. In general, the primary population for analysis is all patients randomized, although a per-protocol population may be used if this is the more conservative approach (e.g., equivalence study).

Prevention of NSAID-related upper gastrointestinal toxicity: a meta-analysis of traditional NSAIDs with gastroprotection and COX-2 inhibitors

Background: Traditional NSAIDs (tNSAIDs) and COX-2 inhibitors (COX-2s) are important agents for the treatment of a variety or arthritic conditions. The purpose of this study was to systematically review the effectiveness of misoprostol, H2-receptor antagonists (H2RAs), and proton pump inhibitors (PPIs) for the prevention of tNSAID related upper gastrointestinal (GI) toxicity, and to review the upper gastrointestinal (GI) safety of COX-2s. Methods: An extensive literature search was performed to identify randomized controlled trials (RCTs) of prophylactic agents used for the prevention of upper GI toxicity, and RCTs that assessed the GI safety of the newer COX-2s. Meta-analysis was performed in accordance with accepted techniques. Results: 39 gastroprotection and 69 COX-2 RCTs met inclusion criteria. Misoprostol, PPIs, and double doses of H2RAs are effective at reducing the risk of both endoscopic gastric and duodenal tNSAID-induced ulcers. Standard doses of H2RAs are not effective at reducing the risk of tNSAID-induced gastric ulcers, but reduce the risk of duodenal ulcers. Misoprostol is associated with greater adverse effects than the other agents, particularly at higher doses. COX-2s are associated with fewer endoscopic ulcers and clinically important ulcer complications, and have fewer treatment withdrawals due to GI symptoms than tNSAIDS. Acetylsalicylic acid appears to diminish the benefit of COX-2s over tNSAIDs. In high risk GI patients, tNSAID with a PPI or a COX-2 alone appear to offer similar GI safety, but a strategy of a COX-2 with a PPI appears to offer the greatest GI safety. Conclusion: Several strategies are available to reduce the risk of upper GI toxicity with tNSAIDs. The choice between these strategies needs to consider patients’ underlying GI and cardiovascular risk.

Teaching in small portions dispersed over time enhances long-term knowledge retention

Background: A primary goal of education is to promote long-term knowledge storage and retrieval. Objective: A prospective interventional study design was used to investigate our research question: Does a dispersed curriculum promote better short- and long-term retention over a massed course? Methods: Participants included 20 gastroenterology residents from the University of Calgary (N = 10) and University of Toronto (N = 10). Participants completed a baseline test of nutrition knowledge. The nutrition course was imparted to University of Calgary residents for 4 h occurring 1 h weekly over 4 consecutive weeks: dispersed delivery (DD). At the University of Toronto the course was taught in one 4h academic half-day: massed delivery (MD). Post-curriculum tests were administered at 1 week and 3 months to assess knowledge retention. Results: The baseline scores were 46.39 ± 6.14% and 53.75 ± 10.69% in the DD and MD groups, respectively. The 1 week post-test scores for the DD and MD groups were 81.67 ± 8.57%, p < 0.001 and 78.75 ± 4.43, p < 0.001 which was significantly higher than baseline. The 3-month score was significantly higher in the DD group, but not in the MD group (65.28 ± 9.88%, p = 0.02 vs. 58.93 ± 12.06%, p = 0.18). The absolute pre-test to 1-week post-test difference was significantly higher at 35.28 ± 7.65% among participants in the DD group compared to 25.0 ± 11.80% in the MD group, p = 0.048. Similarly, the absolute pre-test to 3-month post-test difference was significantly higher at 18.9 ± 6.7% among the participants in the DD group, compared to 6.8 ± 11.8% in the MD group, p = 0.021. Conclusions: Long-term nutrition knowledge is improved with DD compared with MD.

Development and validation of a nurse-assessed patient comfort score for colonoscopy

BACKGROUNDnComfort during colonoscopy is a critical component of safety and quality.nnnOBJECTIVEnTo develop and validate the Nurse-Assessed Patient Comfort Score (NAPCOMS).nnnDESIGNnProspective scale validation.nnnSETTINGnColorectal cancer screening centers in the United Kingdom and Canada.nnnPATIENTSnA total of 300 consecutive patients undergoing colonoscopy at participating colorectal cancer screening centers.nnnINTERVENTIONnThe NAPCOMS was developed by using a modified Delphi process. During colonoscopy, two endoscopy room nurses independently observed and rated patient comfort and tolerability by using NAPCOMS. In addition, endoscopists reported global comfort scores and patients reported global comfort by using visual 4-point Likert and National Health Service-United Kingdom Global Rating Scales.nnnMAIN OUTCOME MEASUREMENTSnReliability and validity of NAPCOMS was measured by using intraclass correlations (ICC) between nurse ratings of colonoscopies and between NAPCOMS, endoscopist ratings, and patient ratings of global comfort.nnnRESULTSnThe ICC for the overall NAPCOMS was 0.84 (95% confidence interval [CI], 0.80-0.87). There was high agreement between the NAPCOMS and endoscopist ratings of comfort (ICC = 0.77; 95% CI, 0.72-0.81), moderate agreement between the NAPCOMS and patient ratings (ICC = 0.61; 95% CI, 0.53-0.67), and moderate agreement between the endoscopist and patient ratings (ICC = 0.52; 95% CI, 0.43-0.60).nnnLIMITATIONSnNAPCOMS was validated in outpatients who received colonoscopy with minimal to moderate sedation as part of a screening and surveillance program, so performance among inpatients or those requiring deep sedation was not tested.nnnCONCLUSIONnNAPCOMS is a reliable and valid tool for assessing patient comfort in the setting of outpatient colonoscopy performed with minimal to moderate sedation.

Colometer: a real-time quality feedback system for screening colonoscopy.

AIMnTo investigate the performance of a new software-based colonoscopy quality assessment system.nnnMETHODSnThe software-based system employs a novel image processing algorithm which detects the levels of image clarity, withdrawal velocity, and level of the bowel preparation in a real-time fashion from live video signal. Threshold levels of image blurriness and the withdrawal velocity below which the visualization could be considered adequate have initially been determined arbitrarily by review of sample colonoscopy videos by two experienced endoscopists. Subsequently, an overall colonoscopy quality rating was computed based on the percentage of the withdrawal time with adequate visualization (scored 1-5; 1, when the percentage was 1%-20%; 2, when the percentage was 21%-40%, etc.). In order to test the proposed velocity and blurriness thresholds, screening colonoscopy withdrawal videos from a specialized ambulatory colon cancer screening center were collected, automatically processed and rated. Quality ratings on the withdrawal were compared to the insertion in the same patients. Then, 3 experienced endoscopists reviewed the collected videos in a blinded fashion and rated the overall quality of each withdrawal (scored 1-5; 1, poor; 3, average; 5, excellent) based on 3 major aspects: image quality, colon preparation, and withdrawal velocity. The automated quality ratings were compared to the averaged endoscopist quality ratings using Spearman correlation coefficient.nnnRESULTSnFourteen screening colonoscopies were assessed. Adenomatous polyps were detected in 4/14 (29%) of the collected colonoscopy video samples. As a proof of concept, the Colometer software rated colonoscope withdrawal as having better visualization than the insertion in the 10 videos which did not have any polyps (average percent time with adequate visualization: 79% ± 5% for withdrawal and 50% ± 14% for insertion, P < 0.01). Withdrawal times during which no polyps were removed ranged from 4-12 min. The median quality rating from the automated system and the reviewers was 3.45 [interquartile range (IQR), 3.1-3.68] and 3.00 (IQR, 2.33-3.67) respectively for all colonoscopy video samples. The automated rating revealed a strong correlation with the reviewers rating (ρ coefficient= 0.65, P = 0.01). There was good correlation of the automated overall quality rating and the mean endoscopist withdrawal speed rating (Spearman r coefficient= 0.59, P = 0.03). There was no correlation of automated overall quality rating with mean endoscopists image quality rating (Spearman r coefficient= 0.41, P = 0.15).nnnCONCLUSIONnThe results from a novel automated real-time colonoscopy quality feedback system strongly agreed with the endoscopists quality assessments. Further study is required to validate this approach.