Vincent Wietlisbach

Impact of colonic cleansing on quality and diagnostic yield of colonoscopy: The European Panel of Appropriateness of Gastrointestinal Endoscopy European multicenter study

BACKGROUND The quality of colon cleansing is a major determinant of quality of colonoscopy. To our knowledge, the impact of bowel preparation on the quality of colonoscopy has not been assessed prospectively in a large multicenter study. Therefore, this study assessed the factors that determine colon-cleansing quality and the impact of cleansing quality on the technical performance and diagnostic yield of colonoscopy. METHODS Twenty-one centers from 11 countries participated in this prospective observational study. Colon-cleansing quality was assessed on a 5-point scale and was categorized on 3 levels. The clinical indication for colonoscopy, diagnoses, and technical parameters related to colonoscopy were recorded. RESULTS A total of 5832 patients were included in the study (48.7% men, mean age 57.6 [15.9] years). Cleansing quality was lower in elderly patients and in patients in the hospital. Procedures in poorly prepared patients were longer, more difficult, and more often incomplete. The detection of polyps of any size depended on cleansing quality: odds ratio (OR) 1.73: 95% confidence interval (CI)[1.28, 2.36] for intermediate-quality compared with low-quality preparation; and OR 1.46: 95% CI[1.11, 1.93] for high-quality compared with low-quality preparation. For polyps >10 mm in size, corresponding ORs were 1.0 for low-quality cleansing, OR 1.83: 95% CI[1.11, 3.05] for intermediate-quality cleansing, and OR 1.72: 95% CI[1.11, 2.67] for high-quality cleansing. Cancers were not detected less frequently in the case of poor preparation. CONCLUSIONS Cleansing quality critically determines quality, difficulty, speed, and completeness of colonoscopy, and is lower in hospitalized patients and patients with higher levels of comorbid conditions. The proportion of patients who undergo polypectomy increases with higher cleansing quality, whereas colon cancer detection does not seem to critically depend on the quality of bowel preparation.

Body mass index, abdominal adiposity and blood pressure: consistency of their association across developing and developed countries

BACKGROUND: Obesity is increasing worldwide because developing countries are adopting Western high-fat foods and sedentary lifestyles. In parallel, in many of them, hypertension is rising more rapidly, particularly with age, than in Western countries.OBJECTIVE: To assess the relationship between adiposity and blood pressure (BP) in a developing country with high average BP (The Seychelles, Indian Ocean, population mainly of African origin) in comparison to a developed country with low average BP (Switzerland, population mainly of Caucasian origin).DESIGN: Cross-sectional health examination surveys based on population random samples.SETTING: The main Seychelles island (Mahé) and two Swiss regions (Vaud-Fribourg and Ticino).SUBJECTS: Three thousand one hundred and sixteen adults (age range 35–64) untreated for hypertension.MEASUREMENTS: Body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), systolic and diastolic blood pressure (SBP and DBP, mean of two measures).METHODS: Scatterplot smoothing techniques and gender-specific linear regression models.RESULTS: On average, SBP and DBP were found to increase linearly over the whole variation range of BMI, WHR and WC. A modest, but statistically significant linear association was found between each indicator of adiposity and BP levels in separate regression models controlling for age. The regression coefficients were not significantly different between the Seychelles and the two Swiss regions, but were generally higher in women than in men. For the latter, a gain of 1.7 kg/m2 in BMI, of 4.5 cm in WC or of 3.4% in WHR corresponded to an elevation of 1 mmHg in SBP. For women, corresponding figures were 1.25 kg/m2, 2.5 cm and 1.8% respectively. Regression coefficients for age reflected a higher effect of this variable on both SBP and DBP in the Seychelles than in Switzerland.CONCLUSION: These findings suggest a stable linear relation of adiposity with BP, independent of age and body fat distribution, across developed and developing countries. The more rapid increase of BP with age observed in the latter countries are likely to reflect higher genetic susceptibility and/or higher cumulative exposure to another risk factor than adiposity.

Prevalence of hyperuricemia and relation of serum uric acid with cardiovascular risk factors in a developing country

BackgroundThe prevalence of hyperuricemia has rarely been investigated in developing countries. The purpose of the present study was to investigate the prevalence of hyperuricemia and the association between uric acid levels and the various cardiovascular risk factors in a developing country with high average blood pressures (the Seychelles, Indian Ocean, population mainly of African origin).MethodsThis cross-sectional health examination survey was based on a population random sample from the Seychelles. It included 1011 subjects aged 25 to 64 years. Blood pressure (BP), body mass index (BMI), waist circumference, waist-to-hip ratio, total and HDL cholesterol, serum triglycerides and serum uric acid were measured. Data were analyzed using scatterplot smoothing techniques and gender-specific linear regression models.ResultsThe prevalence of a serum uric acid level >420 μmol/L in men was 35.2% and the prevalence of a serum uric acid level >360 μmol/L was 8.7% in women. Serum uric acid was strongly related to serum triglycerides in men as well as in women (r = 0.73 in men and r = 0.59 in women, p < 0.001). Uric acid levels were also significantly associated but to a lesser degree with age, BMI, blood pressure, alcohol and the use of antihypertensive therapy. In a regression model, triglycerides, age, BMI, antihypertensive therapy and alcohol consumption accounted for about 50% (R2) of the serum uric acid variations in men as well as in women.ConclusionsThis study shows that the prevalence of hyperuricemia can be high in a developing country such as the Seychelles. Besides alcohol consumption and the use of antihypertensive therapy, mainly diuretics, serum uric acid is markedly associated with parameters of the metabolic syndrome, in particular serum triglycerides. Considering the growing incidence of obesity and metabolic syndrome worldwide and the potential link between hyperuricemia and cardiovascular complications, more emphasis should be put on the evolving prevalence of hyperuricemia in developing countries.

Dyslipidemia and abdominal obesity: an assessment in three general populations.

Several studies show a relationship between abdominal obesity and cardiovascular diseases, partially mediated through an altered metabolism of dyslipidemia. The present study was aimed at testing the robustness of this association across three contrasted populations and at assessing the performances of abdominal obesity as a screening tool for dyslipidemia. Data were drawn from three population health surveys recently conducted in two regions of a developed country (Switzerland, mostly of Caucasian origin, n = 2650) and in a less developed country (Seychelles, Indian Ocean, mostly of black descent, n = 806). Dyslipidemia was defined as a ratio of total cholesterol to high-density lipoprotein cholesterol (TC-HDL) greater than 5. Two anthropometric circumference measurements, waist-to-hip ratio (WHR) and waist circumference (WC), were used to define abdominal obesity either as WHR >/= 0.9 in men and WHR >/= 0.8 in women or as WC >/= 94 cm and WC >/= 80 cm, respectively. A consistent direct association between abdominal obesity and dyslipidemia (odds ratios varying from 1.85 to 4.56) was found in the three populations, independently of gender, age, body mass index, blood pressure, and smoking. This consistency across ethnicities and environments strengthens the hypothesis of a common etiopathological mechanism. The sensitivity for detecting dyslipidemia was generally higher for abdominal obesity, based on either WHR or WC, than for criteria based on the other risk factors under study. In addition, the sensitivity was higher in the study populations with a low prevalence of dyslipidemia (Swiss women and Seychellois of both sexes) than in the others. These findings support that WHR and WC may be useful as simple and inexpensive screening tools to select individuals eligible for more sophisticated and costly serum lipid determinations, especially in developing countries.

High Risk for Hyperlipidemia and the Metabolic Syndrome after an Episode of Hypertriglyceridemia during 13-cis Retinoic Acid Therapy for Acne: A Pharmacogenetic Study

Context Isotretinoin (Accutane, Roche, Basel, Switzerland) is the treatment of choice for severe acne that is resistant to topical treatment. Approximately 20% of patients develop marked elevations in triglyceride levels. The mechanism responsible for isotretinoin-induced hyperlipidemia is unknown. Contribution This study showed that isotretinoin-induced hypertriglyceridemia identifies patients at high risk for chronic hyperlipidemia, truncal obesity, and hyperinsulinemia. The apoE gene and 2 and 4 alleles were more common in patients with isotretinoin-induced hypertriglyceridemia than in patients who had no lipid abnormalities while taking the drug. Implications People with isotretinoin-induced hypertriglyceridemia have increased risks for chronic hyperlipidemia and the metabolic syndrome that are possibly related to the apoE gene. The Editors Lipid abnormalities have been associated with the use of various pharmacologic agents, including -blockers, diuretics, estrogens, HIV-1 protease inhibitors (1), and 13-cis retinoic acid (isotretinoin [Accutane], Roche, Basel, Switzerland) (2, 3). Isotretinoin is the treatment of choice for severe acne resistant to other treatments. In some patients (20%), isotretinoin causes a marked but reversible elevation in plasma concentrations of triglyceride-rich lipoproteins, which can result in acute pancreatitis (4). The severity of this complication has prompted dermatologists to systematically monitor fasting plasma lipid levels whenever they prescribe isotretinoin. The mechanism for isotretinoin-induced hyperlipidemia remains elusive, and it is not known why only a fraction of persons develop this side effect. It is possible that isotretinoin elevates plasma triglyceride levels in patients with acne who have a latent, possibly familial and genetic predisposition to hyperlipidemia. The most common form of familial lipid disorders is familial combined hyperlipidemia (5). This condition shares a series of features with the metabolic syndrome, a multifaceted condition characterized by hyperlipidemia, hypertension, hyperuricemia, insulin resistance, diabetes, and obesity (6-10). Familial combined hyperlipidemia and the metabolic syndrome are usually dormant during childhood and become progressively apparent in adults. Both conditions are major contributors to heart disease. Although these disorders have a familial component (5, 11), the responsible genes have not been identified. Elucidation of the genetic basis of familial combined hyperlipidemia and the metabolic syndrome has been hampered by the heterogeneity of these disorders and their incomplete penetrance, which are consistent with strong geneenvironment interactions. We reasoned that isotretinoin is an environmental trigger that unmasks a latent familial predisposition to hyperlipidemia and the metabolic syndrome. To test our hypothesis, we used a family-based cross-sectional comparison. We initially identified a large group of young adults who had developed a pronounced elevation in plasma triglyceride levels during isotretinoin therapy for acne (hyperresponders) and an equally large group whose plasma triglyceride levels had not changed during therapy (nonresponders). All participants were reevaluated for markers of the metabolic syndrome while not receiving therapy. Parents of hyperresponders and nonresponders were also evaluated. Methods Study Design and Participants Initially, we examined the medical records of 613 persons with acne who had been treated with isotretinoin for at least 4 weeks between 1988 and 1998 at the dermatology division of CHUV University Hospital and at the practices of four dermatologists in the area of Lausanne, Switzerland. For 601 participants (98%), fasting plasma lipid levels had been measured once before initiation of isotretinoin therapy and had then been monitored monthly by the same laboratory. A total of 18 persons were excluded because they had fasting pretreatment plasma cholesterol levels of 7.0 mmol/L or more ( 271 mg/dL), triglyceride levels of 3.0 mmol/L or more ( 266 mg/dL), or both. Thus, 583 persons were included in the analysis (Figure 1). Mean duration of isotretinoin course was 6 months, and an average of six lipid values were available for each participant during treatment. We determined isotretinoin-associated changes in fasting plasma triglyceride level by calculating the difference between the highest value recorded during isotretinoin therapy and the pretreatment level. Hyperresponders (n = 117) were identified as persons who had developed an increase in plasma triglyceride level of 1.0 mmol/L or more ( 89 mg/dL) (corresponding to the upper quintile in the distribution); 145 participants whose plasma triglyceride levels had remained unchanged or decreased during isotretinoin therapy (a difference 0.1 mmol/L [ 9 mg/dL], corresponding to the lower quartile in the distribution) were considered nonresponders. We contacted the hyperresponders and the nonresponders and asked them to participate in our study and to be reevaluated while not receiving therapy. Only 15 hyperresponders and 45 nonresponders were not found or declined to participate. Participation rate was higher for hyperresponders (87%) than nonresponders (69%) (P = 0.001) because of difficulties in motivating healthy persons who had shown no change in plasma lipid levels during isotretinoin therapy. A total of 102 hyperresponders and 100 nonresponders were reevaluated while not receiving therapy. We also contacted the parents of these participants (when both parents were available) and eventually recruited both parents of 71 hyperresponders and 60 nonresponders. The procedures were in accordance with institutional guidelines. The local Ethics Committee approved the protocol, and each participant provided informed consent. Figure 1. Flow chart of the study. Measurements Participants filled out a questionnaire and had a physical examination, including measurement of height, body weight, waist-to-hip ratio, and blood pressure (evaluated using a sphygmomanometer while participants were seated for 10 minutes). Fat mass was estimated by bioelectric impedance using the Bio-Z generator (Eugdia, Paris, France), as described elsewhere (12). Venous blood was collected on EDTA after a 12-hour fast and was processed within 2 hours. Nineteen parents receiving lipid-lowering therapy were asked to stop therapy at least 1 week before they were examined. The clinical chemistry laboratory of Lausanne University Medical Policlinic performed biochemical measurements, as described elsewhere (1). Genomic DNA was isolated from peripheral blood cells, and a series of sequence variations was examined by using polymerase chain reaction amplification and restriction digest, according to published protocols: the 2, 3, and 4 alleles within the apoE gene (13); the Pro12Ala polymorphism within the peroxisome proliferator-activated receptor (PPAR)- gene (14); the C to A substitution at position 278 within the 5 flanking region of the cholesterol 7-hydroxylase (CYP7-) gene (15); and the SstI, XmnI and MspI polymorphisms within the apoAI-CIII-AIV genes (16). Statistical Analyses Data are presented as the mean (SD). Statistical analyses were performed by using SPSS, version 10.0 (SPSS, Inc., Chicago, Illinois). We used t-tests, or Wilcoxon rank-sum tests when appropriate, to compare clinical characteristics. For comparison of frequency distribution, we used the chi-square test or the Fisher exact test. Logistic regression analysis was used to calculate the risk for metabolic disorders associated with a previous elevation in plasma triglyceride levels during isotretinoin therapy. The same type of analysis was performed to evaluate the risk in hyperresponders and nonresponders having one or two parents with metabolic disorders. Role of the Funding Sources None of the funding sources had any role in the design of the study; the collection, analysis, and interpretation of the data; or the decision to submit the manuscript for publication. Results Changes in Plasma Triglyceride Levels during Isotretinoin Therapy Isotretinoin-associated changes in fasting plasma triglyceride level ranged from 0.95 mmol/L (84 mg/dL) to 3.75 mmol/L (332 mg/dL). Average change was 0.57 0.67 mmol/L (50 59 mg/dL). Compared with nonresponders (n = 100), hyperresponders (n = 102) had similar pretreatment body weight (63.3 9.6 kg vs. 64.4 11.4 kg; P > 0.2) and plasma levels of total cholesterol (4.6 0.8 mmol/L [176 32 mg/dL] vs. 4.8 1.0 mmol/L [186 37 mg/dL]; P = 0.07) and triglycerides (1.1 0.4 mmol/L [101 38 mg/dL] vs. 1.2 0.5 mmol/L [104 42 mg/dL]; P > 0.2). Hyperresponders had received a 10% higher dosage of isotretinoin (0.53 0.11 mg/kg of body weight vs. 0.59 0.14 mg/kg of body weight; P = 0.003). Characteristics of Hyperresponders and Nonresponders When Not Receiving Isotretinoin Therapy Hyperresponders and nonresponders were reevaluated 3.8 2.5 years (median, 4 years) after completion of isotretinoin therapy. Mean age was 27.4 7.2 years (range, 16 to 49 years; median, 26 years). In contrast to the pretreatment period, hyperresponders had a higher body mass index and higher fasting plasma concentrations of total cholesterol and triglycerides than nonresponders (Table 1). Moreover, waist-to-hip ratio; fat mass content; systolic blood pressure; plasma levels of low-density lipoprotein cholesterol, apolipoprotein B, and insulin; ratio of total cholesterol to high-density lipoprotein (HDL) cholesterol; and ratio of insulin to glucose were all higher in hyperresponders. Table 1. Characteristics of Hyperresponders and Nonresponders and Their Parents While Not Receiving Isotretinoin Therapy To further characterize the relationship between the lipid response to isotretinoin therapy and the subsequent development of metabolic disorders, we performed logistic regression analysis, using age, sex, apoE genotype, and dose of isotretinoin as covariates (Figure 2). This analysis ind

Minor Clinical Features of Atopic Dermatitis

The diagnostic significance of 8 previously proposed minor features of atopic dermatitis (AD) was evaluated. The minor features studied were: nipple eczema, cheilitis, Dennie-Morgan infraorbital fold,

Relationship between severity of lumbar disc disease and disability scores in sciatica patients.

OBJECTIVE To study the association between the clinical examination and the radiological assessment of lumbar disc disease in patients with sciatica. METHODS The study included 394 consecutive sciatica patients. The patients’ disabilities were evaluated by a visual analog pain scale, the Prolo functional-economic rating scale, the modified Roland-Morris disability questionnaire, and the health-related quality of life short form (SF-36) questionnaire. Radiological imaging findings were independently classified according to the Modic criteria into five groups of increasing severity of disc disease. Stepwise multivariate logistic regression was used to determine which scores were significant independent predictors of a severe disc disease (extrusion or sequestration). RESULTS Of these patients, 9.6% had no disc disease, 3.3% had a bulging, 11.4% had a protrusion, 68.5% had an extrusion, and 7.1% had a disc sequestration. Statistically significant positive linear associations with the severity of disc disease were found for the leg pain scale, the Roland-Morris and Prolo disability scales, and the SF-36 scores related to physical functioning, physical role, and bodily pain (all P < 0.005). A poor (<5) Prolo score (odds ratio, 2.91; 95% confidence interval, 1.74–4.87), a higher leg pain score (odds ratio, 1.16 per centimeter increase; 95% confidence interval, 1.07–1.27), and a lower low back pain score (odds ratio, 0.90 per centimeter decrease; 95% confidence interval, 0.82–0.98) were retained in the multivariate logistic model as independent predictors of severe disc disease. CONCLUSION The positive correlation between disability status and imaging findings validates both assessment methods. Routine use of disability scores brings a useful contribution to the assessment of sciatica patients.

Infections and Functional Impairment in Nursing Home Residents: A Reciprocal Relationship

Objectives: To determine the relationship between infections and functional impairment in nursing home residents.

Helicobacter pylori eradication treatment does not benefit patients with nonulcer dyspepsia

OBJECTIVES:The aim of this study was to assess the still controversial role of treatment of Helicobacter pylori (H. pylori) infection in patients with nonulcer dyspepsia.METHODS:We conducted a double-blind, randomized, placebo-controlled, multicenter trial comparing the efficacy of 7 days of eradication treatment (lansoprazole 15 mg b.i.d., amoxicillin 1 g b.i.d., and clarithromycin 500 mg b.i.d.) with a control treatment (lansoprazole 15 mg b.i.d. and placebo) in H. pylori-infected patients with nonulcer dyspepsia. 13C breath tests were performed at baseline and during follow-up. We assessed patient symptoms, health status (based on the SF-12 questionnaire), patient satisfaction, drug consumption, health care consultation behavior, and absenteeism related to dyspepsia over a 1-yr period.RESULTS:A total of 74 patients randomized to eradication treatment and 70 patients randomized to placebo were compared. The rate of eradication of H. pylori infection was 75% in the active treatment group and 4% in the placebo group (p < 0.005). The symptom score improved to a similar extent in the group receiving active treatment (−4.0; 95% CI =− 5.0 to −3.0) and placebo (−3.6; 95% CI =− 4.5 to −2.7). Treatment response was not related to the severity or duration of initial symptoms or to the severity of gastritis on histology. Quality of life scores were comparable at 12 months. There was no significant difference in dyspepsia-related absenteeism or satisfaction with management of NUD. Patients receiving active treatment were more likely not to have had to use any dyspepsia treatment over the 12 months (60.8% vs 44.3%; p = 0.047).CONCLUSIONS:This study did not demonstrate any substantial benefit of curing H. pylori infection in patients with nonulcer dyspepsia. The study adds further evidence that H. pylori is not the main pathogenetic or therapeutic target in these patients.

One-year prevalence of low back pain in two Swiss Regions : Estimates from the population participating in the 1992-1993 MONICA project

Study Design. A cross-sectional survey was performed. Objective. To estimate the extent of low back pain as a public health problem. Summary of Background Data. Health surveys converge on very high estimates of low back pain in general populations, but few studies have included severity criteria in their definition and conclusions. Because it is unlikely that interventions will influence the prevalence of minimal and infrequent symptoms, greater attention should be paid to characteristics of low back pain that indicate some impact on the life of survey respondents. Methods. Two regions participated in the MONICA (MONitoring of trends and determinants in CArdiovascular disease) project in Switzerland. Participants randomly selected from the general population completed a standard self-administered questionnaire on cardiovascular risk factors. A special section on low back pain was added in the third (1992–1993) MONICA survey and completed by 3227 participants. Results. A regional difference found in the 12-month prevalence rate disappeared with the inclusion of severity criteria. Low back pain over more than seven cumulated days was reported among men by 20.2% (age range, 25–34 years) to 28.5% (age range, 65–74 years), respectively, among women by 31.1% to 38.5%. Similar rates of reduction in activity (professional, housekeeping, and leisure time) and medical consultation (conventional and nonconventional) motivated by low back pain characterized the two participating regions. The cumulative duration of pain was related to all the indicators showing the impact of low back pain on everyday life. Conclusions. Determining the cumulative duration of low back pain over the preceding year is a straightforward task, and a cutoff at 1 week seems appropriate for distinguishing between low- and high-impact low back pain.