Electra D. Paskett

Virtual colonoscopy using oral contrast compared with colonoscopy for the detection of patients with colorectal polyps

BACKGROUND & AIMS Virtual colonoscopy using abdominal spiral computed tomography scanning allows total colonic evaluation with minimal invasiveness. Two-dimensional images and selective 3-dimensional images of the colon are used to detect colorectal lesions. This trial used conventional colonoscopy with segmental unblinding to determine the ability of virtual colonoscopy to identify patients with colorectal lesions who need conventional colonoscopy. METHODS We studied 205 patients with virtual colonoscopy using oral iodinated contrast preceding conventional colonoscopy. Colonic lavage was achieved with an oral sodium phosphosoda preparation and colonic distention with a carbon dioxide electronic insufflator. RESULTS The overall sensitivity and specificity of virtual colonoscopy in identifying patients with colorectal lesions was 61.8% and 70.7%, respectively. Virtual colonoscopy was more accurate in identifying patients with lesions >/=6 mm (sensitivity 84.4% and specificity 83.1%) and those with lesions >/=10 mm (sensitivity 90% and specificity 94.6%). The negative predictive value of virtual colonoscopy was 95% for a 6-mm cutoff size and 98.9% for a 10-mm cutoff. Using a 10-mm cutoff, virtual colonoscopy precludes the need for conventional colonoscopy in 86% of patients with a 1% false-negative rate (68% with a 3.4% false-negative rate when using a 6-mm cutoff). CONCLUSIONS Virtual colonoscopy has a high sensitivity and specificity for detecting patients with significant colorectal lesions. Its high negative predictive value may help reduce the number of negative screening colonoscopies. Further studies are needed to determine what lesion cutoff size is clinically acceptable and the appropriate interval time for repeat virtual colonoscopy when it detects lesions below this cutoff size.

Is colonoscopy needed for the nonadvanced adenoma found on sigmoidoscopy

Abstract Background & Aims: The need for colonoscopy when small tubular adenomas with low-grade dysplasia are found on sigmoidoscopy is uncertain. The aim of this study was to examine the prevalence and characteristics of proximal adenomas in patients with distal adenomas. Methods: We studied 981 subjects with distal adenomas found on the index colonoscopy before randomization in the Polyp Prevention Trial. Results: Four hundred sixty patients (46.9%) had ≥1 distal adenoma that was pathologically advanced (villous component, high-grade dysplasia, or ≥1 cm); 21.5% (211 of 981) had any proximal adenoma; and 4.3% (42 of 981) (95% confidence interval [CI], 3.0–5.5) had an advanced proximal adenoma. A greater percentage of patients with an advanced distal adenoma (5.9%) (95% CI, 3.7–8.0) had an advanced proximal adenoma compared with those with a nonadvanced distal adenoma (2.9%) (95% CI, 1.4–4.3) (OR, 2.1; 95% CI, 1.1–4.3; P = 0.03). Not performing a colonoscopy in patients with a nonadvanced distal adenoma would have missed 36% (15 of 42) of the advanced proximal adenomas. Conclusions: Patients with an advanced distal adenoma are twice as likely to have an advanced proximal adenoma as patients with a nonadvanced distal adenoma. However, eschewing a colonoscopy in patients with a nonadvanced distal adenoma would result in not detecting a sizeable percentage of the prevalent advanced proximal adenomas. These data support performance of a colonoscopy in patients with a nonadvanced distal adenoma. Confirmation of these results in asymptomatic subjects undergoing screening sigmoidoscopy is advisable. GASTROENTEROLOGY 1998;115:533-541

Lymphedema: Knowledge, Treatment, and Impact Among Breast Cancer Survivors.

Abstract: Lymphedema is an understudied consequence of surgery for breast cancer. It is estimated that as many as 60% of breast cancer survivors report symptoms of lymphedema. Few studies have examined the impact of lymphedema on the lives of women with breast cancer. The goal of this pilot study was to identify knowledge about, treatment received for, and the effect of lymphedema among a group of breast cancer survivors and physicians. Forty women with lymphedema and 10 physicians who treat breast cancer patients participated. Overall, women knew little to nothing about lymphedema before they developed it. After diagnosis, the primary source of information about lymphedema was a doctor or physical therapist. The majority of women received compressive garment therapy (75%), 46.9% received mechanical compressive therapy, 26% received bandaging, and 22% received physical therapy. More than half (55%) reported that clothing and appearance were affected by their condition and 48% reported that routine daily activities were impaired. Hot weather (58%) and regular arm use (40%) were reported to exacerbate the swelling. Most physicians reported that they did not routinely counsel women or provide written information on lymphedema prevention to their patients, and the extent to which womens daily living was affected by the condition was not always recognized. These findings have implications for interventions aimed at educating women and providers about lymphedema.

Improving follow-up after an abnormal Pap smear: a randomized controlled trial.

Less than 60% of women diagnosed with cervical abnormalities on Pap smears return for proper surveillance and timely treatment. Previous tactics used to motivate these women to return have mainly relied on costly intensive recall efforts. Using a framework based on psychological value expectancy theory, a pamphlet was designed to motivate women with abnormal Pap smears to return for a repeat Pap smear. The effect of this pamphlet was tested in a randomized controlled trial. A total of 161 women with abnormal Pap smears were randomized and received either the pamphlet plus a notification letter or the letter only. The compliance rate was 64.2% in the intervention group and 51.3% in the comparison group (P = 0.10; two-tailed). In addition, subgroups of women who do not practice health-related behaviors were identified as groups where more intensive interventions may be needed. These results have implications for future strategies used to recall women with abnormal Pap smears.

Compliance Behavior in Women With Abnormal Pap Smears: Developing and Testing a Decision Model

This study investigated the reasons why women choose whether or not to seek treatment after being notified about an abnormal Pap smear in a womens clinic in Seattle. A hierarchic weighted utility model was developed from in-depth open-ended interviews with women who had an abnormal Pap smear and was used to identify beliefs and values related to the decision to seek treatment, i.e., a repeat Pap smear, for an abnormal Pap smear. Interviews with 18 women who had an abnormal Pap smear produced 12 issues pertinent to the behavior in question. These issues were grouped to form the hierarchy, and the decision model was then administered to 44 additional women. The model accurately classified the compliance behavior of 68% of study subjects. Moreover, the model differentiated persons who sought treatment for an abnormal Pap smear along several important dimensions: 1) doctors opinion; 2) the accuracy or seriousness of the Pap smear result; 3) the importance of early detection; 4) familiarity with the treatment procedure; 5) time hassles (i.e., difficulties) involved in getting further treatment; 6) femininity concerns; 7) fear of cancer; and 8) perceived risk of cancer. These dimensions suggest specific content areas that may be used to develop low-cost compliance intervention strategies for use in clinical settings.

Non-steroidal anti-inflammatory drug use is associated with reduction in recurrence of advanced and non-advanced colorectal adenomas (United States).

Objective: To prospectively examine the association between non-steroidal anti-inflammatory drugs (NSAIDs) use (including dose and dosage schedule) and the recurrence of colorectal adenomas among individuals who were diagnosed with an adenoma at entry into a clinical trial. Methods: For this analysis, participants who completed the full follow-up (n = 1905) for the Polyp Prevention Trial (PPT) were evaluated. Information on current use and dose of NSAIDs and other drugs was obtained at baseline and at each subsequent study visit over the duration of the trial. The study endpoint was the recurrence of colorectal adenomas in the 3 years between the 1-year trial colonoscopy (T1) and the end of the trial colonoscopy (T4). Results: There was a significant reduction in overall adenoma recurrence among NSAIDs users (odds ratio [OR] = 0.77; 95% confidence interval [CI]: 0.63–0.95), with the greatest effect seen in advanced polyps (OR = 0.51; CI: 0.33–0.79). Among aspirin users, we observed a significant dose response for overall adenoma recurrence, with a 40% reduction in the OR association (OR = 0.56; 95% CI: 0.31–0.99) among those taking more than 325 mg per day. Conclusion: This prospective study provides further evidence that NSAIDs may play an important role in the chemoprevention of recurrent colorectal adenomas, even those with advanced features.

Improving compliance among women with abnormal papanicolaou smears

Objective To determine whether a clinic-based intervention, consisting of motivational brochures and a tracking system, increases adherence to recommendations for treatment in women with abnormal Papanicolaou smears. Methods Three pairs of clinics—two family planning clinics, two family practice clinics, and two dysplasia clinics—were randomized within pairs either to provide the intervention or to maintain usual contact procedures with women having abnormal Papanicolaou smears. Baseline adherence rates were assessed through chart review during 3 randomly selected months of the previous year. Intervention clinics received the tracking system and motivational brochures, which were sent to women on notification of their cervical abnormalities. Comparison clinics also used the tracking system but did not include the brochures when notifying women of their abnormalities. Adherence rates were assessed prospectively for approximately 100 consecutive nonpregnant women with abnormal Papanicolaou smears (inflammatory benign atypia, or cervical intraepithelial neoplasia I, II, or III) at each clinic. Results Within clinics, baseline adherence rates ranged from 34–69% for atypia and 33–88% for dysplasia. For dysplasia patients, the overall analysis indicated a significant increase in adherence for the intervention clinics (P = .03); however, for atypia patients, the observed difference was not statistically significant (P = .23). Extensive analyses of the data from family planning clinics indicated that women receiving the intervention were more likely to obtain follow-up treatment (odds ratio [OR] 2.6, 95% confidence interval 1.15–5.85). There was a suggestion that the interven-tion could have a greater effect among African-American women (OR 15.7) compared with white women (OR 1.8) (P = .09). White women, those with dysplasia, nonsmokers, and nulliparas were most likely to adhere to treatment recommendations. Conclusion A motivational brochure can enhance adherence to treatment recommendations among women with abnormal Papanicolaou smears. Future studies should focus on techniques for enhancing adherence among more resistant participants.

Characteristics of men reporting for prostate cancer screening

A survey to determine demographics, prostate cancer screening practices, and prostate cancer-related knowledge and beliefs was administered to over 1,700 participants at five sites during Prostate Cancer Awareness Week (1991) screening events. Findings are presented by site since significant differences in demographics existed. Results suggest that screenings conducted at the major medical centers attract primarily white males, a number of whom already practice adequate secondary prevention. Thus, if optimal benefit is sought through mass prostate cancer screening, innovative strategies to reach populations that are currently underserved and at risk are necessary.

Self-rated quality of life measures: Effect of change to a low-fat, high-fiber, fruit and vegetable enriched diet

The Polyp Prevention Trial (PPT) was a multicenter, randomized clinical trial to determine the effect of a low-fat (20% of energy from fat), high-fiber (18 g/1000 kcal/day), high-fruit/vegetable (3.5 servings/1000 kcal/day) eating plan on the recurrence of large bowel adenomatous polyps. The PPT provided an opportunity to examine the impact of dietary changes on quality of life. At baseline and annually for 4 years, participants in the Quality of Life Substudy of PPT completed a Quality of Life Factors (QF) Questionnaire, a modified Block-National Cancer Institute Food Frequency Questionnaire, and a Health and Lifestyle Questionnaire. The 51-item QF Questionnaire assessed changes in nine domains: taste, convenience, cost, self-care, social, health assessment, health belief, health action, and life satisfaction. The analysis compared annual changes in domain scores for intervention (n = 194) and control (n = 200) participants. At Year 1, 363 (92%) completed a questionnaire, and 325 (82%) participants completed a Year 4 questionnaire. There were no statistically significant differences between treatment groups in the change from baseline to Year 1 for the convenience, cost, taste, health assessment, and life satisfaction domains. At Year 1, intervention participants rated the self-care (p < .001), health belief (p = .021), and health action (p < .001) domains significantly higher and the social domain significantly lower (p < .001) than control participants. These changes were consistent through Years 2, 3, and 4. This study

The Osteoporosis Prevention and Arterial effects of tiboLone (OPAL) study: design and baseline characteristics

The Osteoporosis Prevention and Arterial effects of tiboLone (OPAL) trial is a three-arm, randomized, placebo-controlled, double-blind study to determine the effect of tibolone 2.5 mg (Org OD 14) and continuous combined conjugated equine estrogens plus medroxyprogesterone acetate (0.625 mg/2.5 mg respectively) on progression of intima-media thickness of the carotid arteries and bone mineral density of the lumbar vertebrae and proximal femur in postmenopausal women. A total of 866 healthy postmenopausal women were recruited in six U.S. centers and five European centers. Duplicate carotid ultrasound examinations of the common carotid artery, the carotid bifurcation, and the internal carotid artery were performed at baseline. Single measurements of bone mineral density of the lumbar vertebrae and proximal femur were obtained at baseline. After randomization, ultrasound examinations were repeated every 6 months for 36 months following baseline, with a duplicate examination at the end of the study. Bone mineral density was measured every 12 months throughout the trial. The primary outcome is change in mean common carotid intima-media thickness (CIMT), defined as the average of the intima-media thickness measurements performed circumferentially at predefined angles for the near and far wall of 10-mm segments of the right and left distal common carotid arteries. Unique new features of the OPAL study are the specifically developed OPAL ultrasound protocol, yielding highly reproducible CIMT measurements, and the use of two experienced core laboratories for CIMT readings (one in the United States and one in Europe) with one common quality assurance and control program. The OPAL study is a large, placebo-controlled trial evaluating the effects of tibolone, as well as one of the first large randomized studies to determine the effects of continuous combined estrogen-progestin therapy on carotid atherosclerosis in healthy postmenopausal women. The OPAL study results are expected to complement other studies on atherosclerosis progression in healthy postmenopausal women.