Samir C. Grover

Wikipedia: a key tool for global public health promotion.

The Internet has become an important health information resource for patients and the general public. Wikipedia, a collaboratively written Web-based encyclopedia, has become the dominant online reference work. It is usually among the top results of search engine queries, including when medical information is sought. Since April 2004, editors have formed a group called WikiProject Medicine to coordinate and discuss the English-language Wikipedia’s medical content. This paper, written by members of the WikiProject Medicine, discusses the intricacies, strengths, and weaknesses of Wikipedia as a source of health information and compares it with other medical wikis. Medical professionals, their societies, patient groups, and institutions can help improve Wikipedia’s health-related entries. Several examples of partnerships already show that there is enthusiasm to strengthen Wikipedia’s biomedical content. Given its unique global reach, we believe its possibilities for use as a tool for worldwide health promotion are underestimated. We invite the medical community to join in editing Wikipedia, with the goal of providing people with free access to reliable, understandable, and up-to-date health information.

Gastrointestinal Endoscopy Competency Assessment Tool: development of a procedure-specific assessment tool for colonoscopy.

BACKGROUND Ensuring competence remains a seminal objective of endoscopy training programs, professional organizations, and accreditation bodies; however, no widely accepted measure of endoscopic competence currently exists. OBJECTIVE By using Delphi methodology, we aimed to develop and establish the content validity of the Gastrointestinal Endoscopy Competency Assessment Tool for colonoscopy. DESIGN An international panel of endoscopy experts rated potential checklist and global rating items for their importance as indicators of the competence of trainees learning to perform colonoscopy. After each round, responses were analyzed and sent back to the experts for further ratings until consensus was reached. MAIN OUTCOME MEASUREMENTS Consensus was defined a priori as ≥80% of experts, in a given round, scoring ≥4 of 5 on all remaining items. RESULTS Fifty-five experts agreed to be part of the Delphi panel: 43 gastroenterologists, 10 surgeons, and 2 endoscopy managers. Seventy-three checklist and 34 global rating items were generated through a systematic literature review and survey of committee members. An additional 2 checklist and 4 global rating items were added by Delphi panelists. Five rounds of surveys were completed before consensus was achieved, with response rates ranging from 67% to 100%. Seven global ratings and 19 checklist items reached consensus as good indicators of the competence of clinicians performing colonoscopy. LIMITATIONS Further validation required. CONCLUSION Delphi methodology allowed for the rigorous development and content validation of a new measure of endoscopic competence, reflective of practice across institutions. Although further evaluation is required, it is a promising step toward the objective assessment of competency for use in colonoscopy training, practice, and research.

An evaluation of Wikipedia as a resource for patient education in nephrology.

Wikipedia, a multilingual online encyclopedia, is a common starting point for patient medical searches. As its articles can be authored and edited by anyone worldwide, the credibility of the medical content of Wikipedia has been openly questioned. Wikipedia medical articles have also been criticized as too advanced for the general public. This study assesses the comprehensiveness, reliability, and readability of nephrology articles on Wikipedia. The International Statistical Classification of Diseases and Related problems, 10th Edition (ICD‐10) diagnostic codes for nephrology (N00–N29.8) were used as a topic list to investigate the English Wikipedia database. Comprehensiveness was assessed by the proportion of ICD‐10 codes that had corresponding articles. Reliability was measured by both the number of references per article and proportion of references from substantiated sources. Finally, readability was assessed using three validated indices (Flesch‐Kincaid grade level, Automated readability index, and Flesch reading ease). Nephrology articles on Wikipedia were relatively comprehensive, with 70.5% of ICD‐10 codes being represented. The articles were fairly reliable, with 7.1 ± 9.8 (mean ± SD) references per article, of which 59.7 ± 35.0% were substantiated references. Finally, all three readability indices determined that nephrology articles are written at a college level. Wikipedia is a comprehensive and fairly reliable medical resource for nephrology patients that is written at a college reading level. Accessibility of this information for the general public may be improved by hosting it at alternative Wikipedias targeted at a lower reading level, such as the Simple English Wikipedia.

High-grade rectal impaction by feces and oral contrast: case report and images.

with urinary tract infection and treated with piperacillin and tazobactam. While in the hospital, she was started on MA 400 mg/d for anorexia and weight loss. After improvement with antibiotics and hydration, she was discharged back to the nursing home, where she was noted to be alert with a blood pressure of 121/80 mmHg but appeared generally weak with a voice just above an audible whisper. One month after MA was started, her systolic blood pressure had gradually decreased to the 80s, and she remained alert, but her generalized weakness and anorexia had worsened, and she became bedbound, being unable to stand or walk without assistance. Her blood chemistry was significant for sodium of 133 mmol/L (normal range 135–142 mmol/L) but was otherwise unremarkable, including thyroid function test. Morning cortisol (3.1 lg/dL, normal range 6.0–22.4 lg/dL) and adrenocorticotropic hormone (ACTH) were low (<5 pg/mL, normal range 5–27 pg/mL). MA-related AI was suspected. Dexamethasone 0.5 mg twice a day was started for clinical response because dexamethasone would not affect cosyntropin stimulation test. MA was tapered and discontinued. Cosyntropin stimulation test revealed a blunted adrenal response to intramuscular cosyntropin 250 lg with cortisol levels of 2.8 lg/dL at 0 minutes, 7.7 lg/dL at 30 minutes, and 13.1 lg/dL at 60 minutes. Brain magnetic resonance imaging did not show tumor. She made remarkable improvements. Her appetite significantly improved, her blood pressure normalized, and her soft voice resolved. Her general weakness also improved to the point where she could ambulate short distances with a walker. More importantly, she regained a great measure of her quality of life, to the point that she was able to go on outings with her family. This case illustrates the importance of keeping AI in the differential diagnosis in cases in which an elderly adult presents with a constellation of symptoms of which each symptom individually, such as generalized weakness, can suggest a myriad of differential diagnoses. In addition, in cases in which an individual is taking MA, the risk of AI should be kept in mind. With a wider recognition of the side effects of MA and awareness that it is on the Beers criteria for potentially inappropriate medications for older adults, MA should be used judiciously, weighing the risks and benefits. MA is a synthetic progestational agent that has been used for breast and endometrial cancer and as an appetite stimulant for anorexia and cachexia. AI can be categorized into primary and secondary AI. In this case, AI was secondary, caused by MA-induced suppression of ACTH secretion, which in turn caused decreased cortisol production. MA is known to have glucocorticoid-like activity, which can suppress the hypothalamic–pituitary– adrenal axis. Doses as low as 160 mg/d can suppress ACTH secretion. Uncorrected or untreated, AI can lead to death. The presentation of AI can be nonspecific, increasing the risk of delayed diagnosis or misdiagnosis. One cross-sectional study of 216 individuals found that more than 67% had consulted at least three physicians and that 68% were primarily falsely diagnosed. Especially in elderly adults, AI symptoms such as fatigue, loss of energy, anorexia, weight loss, and decreased functional status may be relegated to failure to thrive and frailty, when in fact the principle of Occam’s Razor applies. In the case of AI, this diagnosis will account for a myriad of clinical symptoms. Clinicians taking care of elderly adults should include AI in the differential diagnosis.

Effect of Standardised Scoring Conventions on Inter-rater Reliability in the Endoscopic Evaluation of Crohn’s Disease

BACKGROUND AND AIMS The Crohns Disease Endoscopic Index of Severity [CDEIS] and Simplified Endoscopic Score for Crohns Disease [SES-CD] demonstrate consistent overall intra- and inter-rater reliability. However, the reliability of some index items is relatively poor. We evaluated scoring conventions to improve the reliability of these items. METHODS Five gastroenterologists with no previous experience scoring the CDEIS or SES-CD were trained on their use. A total of 65 video recordings of colonoscopies were scored blindly by each gastroenterologist before and after additional training on index scoring conventions. Intra-class correlation coefficients [ICCs] assessed the effect of application of these conventions on the reliability of the CDEIS, SES-CD, and a Global Evaluation of Lesion Severity [GELS] score. RESULTS Following training on scoring conventions, inter-rater ICCs (95% confidence interval [CI]) for the total SES-CD score increased from 0.78 [0.71, 0.85] to 0.85 [0.79, 0.89]. The ICCs for the total CDEIS and GELS scores were not affected: corresponding inter-rater ICCs were 0.74 [0.65, 0.81] and 0.49, [0.38, 0.61] before and 0.73 [0.65, 0.81] and 0.53 [0.42, 0.64] following application of scoring conventions. Estimations of ulcer depth, surface area, anatomical location, and stenosis were important sources of variability. CONCLUSIONS Use of scoring conventions previously developed by expert central readers enhanced the reliability of the SES-CD but did not similarly affect the CDEIS or GELS. As the SES-CD is more likely to be reliable than the CDEIS and can be optimised with targeted training, it is the preferred instrument for use in clinical trials.

small bowel obstruction following computed tomography and magnetic resonance enterography using psyllium seed husk as an oral contrast agent

The authors report a case series describing four patients who developed small bowel obstruction following the use of psyllium seed husk as an oral contrast agent for computed tomography or magnetic resonance enterography. Radiologists who oversee computed tomography and magnetic resonance enterography should be aware of this potential complication when using psyllium seed husk and other bulking agents, particularly when imaging patients with known or suspected small bowel strictures or active inflammation.

Surgical Residents’ Perceptions on Learning Gastrointestinal Endoscopy: More Hours and More Standardization Wanted

OBJECTIVE Gastrointestinal endoscopy is a complex task that involves an interaction of cognitive and manual skills. There is no consensus on the optimal way to teach endoscopy. We sought to evaluate our formal endoscopy curriculum for general surgery trainees to improve the effectiveness and quality of the endoscopy teaching in this program. DESIGN We conducted focus group sessions over a 2-year period. Participants were general surgery residents, who are at the end of their endoscopy training rotation. The goal was to obtain the opinions and perceptions of trainees actively involved in learning endoscopy. SETTING University-based general surgery residency. PARTICIPANTS Second-year general surgery residents. RESULTS A total of 24 residents participated in 7 focus group sessions over 2 years. Four central themes emerged that included training structure and expectations, development of endoscopy competence, teaching approaches and teaching tools, and recommendations for improvement of the training experience. CONCLUSIONS An assessment of the themes led to the following concrete suggestions for improvement: the development of an algorithmic approach to endoscopy for the novice learner, consideration to introduce additional experience in endoscopy later in the 5-year surgery program, and consideration to incorporate a train-the-trainer curriculum for faculty that teach endoscopy.

Red Blood Cell Transfusions and Iron Therapy for Patients Presenting with Acute Upper Gastrointestinal Bleeding: A Survey of Canadian Gastroenterologists and Hepatologists

Introduction. There is limited data evaluating physician transfusion practices in patients with acute upper gastrointestinal bleeding (UGIB). Methods. A web-based survey was sent to 500 gastroenterologists and hepatologists across Canada. The survey included clinical vignettes where physicians were asked to choose transfusion thresholds. Results. The response rate was 41% (N = 203). The reported hemoglobin (Hgb) transfusion trigger differed by up to 50 g/L. Transfusions were more liberal in hemodynamically unstable patients compared to stable patients (mean Hgb of 86.7 g/L versus 71.0 g/L; p < 0.001). Many clinicians (24%) reported transfusing a hemodynamically unstable patient at a Hgb threshold of 100 g/L and the majority (57%) are transfusing two units of RBCs as initial management. Patients with coronary artery disease (mean Hgb of 84.0 g/L versus 71.0 g/L; p < 0.01) or cirrhosis (mean Hgb of 74.4 g/L versus 71.0 g/L; p < 0.01) were transfused more liberally than healthy patients. Fewer than 15% would prescribe iron to patients with UGIB who are anemic upon discharge. Conclusions. The transfusion practices of gastroenterologists in the management of UGIB vary widely and more high-quality evidence is needed to help assess the efficacy and safety of selected transfusion thresholds in varying patients presenting with UGIB.

Capecitabine induced colitis.

Capecitabine is an oral prodrug to 5-fluorouracil and is commonly used in the treatment of advanced breast, colon and stomach cancer. While gastrointestinal toxicity is common, enterocolitis and ischemic colitis are uncommon complications and the histologic features of capecitabine in the colonic mucosa have not been previously described. We present a case of colitis attributed to capecitabine toxicity in a 45-year-old man undergoing treatment of metastatic gastroesophageal adenocarcinoma. Possible pathophysiologic mechanisms of capecitabine toxicity are discussed and the histologic effects on the colon are described.

Financial Conflicts of Interest in Inflammatory Bowel Disease Guidelines

BACKGROUND Industry payments can lead to financial conflicts of interest (FCOI) among authors of clinical practice guidelines (CPGs). Guidelines for inflammatory bowel disease (IBD) may be at particularly high risk. We determined the prevalence of FCOI in IBD CPGs produced by various gastroenterology societies. METHODS We conducted a cross-sectional analysis of FCOI disclosure among CPGs related to the management of IBD. We ascertained the prevalence and types of FCOI for each guideline and determined adherence to National Academy of Medicine (NAM) standards. FCOI disclosures were compared between societies producing CPGs. RESULTS We identified 11 relevant CPGs with 173 total authors. There were 117 (68%) authors who declared a payment. A total of 107 (62%) authors declared FCOI related to a medication recommended in the guideline. There was a significant difference (P < 0.001) between the proportion of authors with FCOI between countries or regions. Authors of US CPGs had a significantly lower FCOI prevalence (19%) compared with other societies. Authors of UK CPGs had a significantly lower FCOI prevalence (56%) compared with Canadian (84%) and European (94%) CPGs. Three (27%) guidelines adhered to both NAM standards. CONCLUSIONS A substantial portion of authors of IBD CPGs had FCOI. Our study found a significant difference in FCOI prevalence based on CPG sponsor nationality. Most CPGs for IBD did not adhere to NAM standards for FCOI disclosure.