Achieving high quality colonoscopy: using graphical representation to measure performance and reset standards.

AIM: Completeness and thoroughness of colonoscopy are measured by the caecal intubation rate (CIR) and the adenoma detection rate (ADR). National standards are ≥ 90% and ≥ 10% respectively. Variability in CIR and ADR have been demonstrated but comparison between individuals and units is difficult. We aimed to assess the performance of colonoscopy in endoscopy units in the northeast of England. METHOD: Data on colonoscopy performance and sedation use were collected over 3 months from 12 units. Colonoscopies performed by screening colonoscopists were included for the CIR only. Funnel plots with upper and lower 95% confidence limits for CIR and ADR were created. RESULTS: CIR was 92.5% (n = 5720) and ADR 15.9% (n = 4748). All units and 128 (99.2%) colonoscopists were above the lower limit for CIR. All units achieved the ADR standard with 10 above the upper limit. Ninety-nine (76.7%) colonoscopists were above 10%, 16 (12.4%) above the upper limit and 7 (5.4%) below the lower limit. Median medication doses were 2.2 mg midazolam, 29.4 mg pethidine and 83.3 µg fentanyl. In all, 15.1% of colonoscopies were unsedated. Complications were bleeding (0.10%) and perforation (0.02%). There was one death possibly related to bowel preparation. CONCLUSION: Results indicate that colonoscopies are performed safely and to a high standard. Funnel plots can highlight variability and areas for improvement. Analyses of ADR presented graphically around the global mean suggest that the national standard should be reset at 15%.

The "improved" public house, 1870-1950: the key to civilized drinking or the primrose path to drunkenness?

The Victorian temperance movement aimed to eliminate, not reform, public houses, but from 1870 interest began to be taken in promoting an "improved" public house which could promote counter-attractions to drink. Disinterested management, based upon public ownership or a trust company, was advocated as the best means of achieving this. There was, however, an ambiguity about the nature of the "improved" public house. Was the goal an austere establishment where the drinking could be controlled in the public interest, or was it a comfortable leisure centre which would promote civilized drinking? This ambiguity lay unresolved during the period of the Carlisle experiment in state control in the period after 1915. Increasingly during the inter-war years the policies of the state-run Carlisle scheme and the more go-ahead brewers converged. The issue was originally conceptualized as a moral one, then as one of national efficiency and finally as a commercial one.

Open access gastroscopy findings are unrelated to the use of aspirin and non-steroidal anti-inflammatory drugs.

This study aims to determine whether priority should be given to patients taking non-steroidal anti-inflammatory drugs (NSAIDs) or aspirin when selecting which dyspeptic patients to refer for open access gastroscopy. A total of 8156 patients underwent gastroscopy, all of whom had upper gastrointestinal symptoms. Patients taking NSAIDs or aspirin showed no significant differences in the frequency of ulcer disease when age-matched groups were compared. Although NSAIDs and aspirin are frequently implicated in gastrointestinal bleeding in the elderly, patients referred for investigation of dyspepsia show no increase in major endoscopic pathology.

Digoxin toxicity presenting as encephalopathy.

We describe two cases of digoxin toxicity presenting with clinical and electroencephalographic evidence of encephalopathy without other features of digoxin toxicity.