Gender differences in predictors of colorectal cancer screening uptake: a national cross sectional study based on the health belief model.

BACKGROUND: Colorectal Cancer (CRC) is rapidly rising in Asia, but screening uptake remains poor. Although studies have reported gender differences in screening rates, there have been few studies assessing gender specific perceptions and barriers towards CRC screening, based on behavioral frameworks. We applied the Health Belief Model to identify gender-specific predictors of CRC screening in an Asian population. METHODS: A nationwide representative household survey was conducted on 2000 subjects aged 50 years and above in Singapore from 2007 to 2008. Screening behaviour, knowledge and beliefs on CRC screening were assessed by face-to-face structured interviews. The response rate was 88.2%. RESULTS: 26.7 percent had undergone current CRC screening with no gender difference in rates. Almost all agreed that CRC would lead to suffering (89.8%), death (84.6%) and would pose significant treatment cost and expense (83.1%). The majority (88.5%) agreed that screening aids early detection and cure but only 35.4% felt susceptible to CRC. Nearly three-quarters (74.3%) of the respondents recalled reading or hearing information on CRC in the print or broadcast media. However, only 22.6% were advised by their physicians to undergo screening. Significantly more women than men had feared a positive diagnosis, held embarrassment, pain and risk concerns about colonoscopy and had friends and family members who encouraged screening. On multivariate analysis, screening uptake showed a positive association with worry about contracting CRC and a physician's recommendation and a negative association with perceived pain about colonoscopy for both genders. For women only, screening was positively associated with having attended a public talk on CRC and having a family member with CRC, and was negatively associated with Malay race and perceived danger of colonoscopy. CONCLUSIONS: CRC screening remains poor despite high levels of awareness of its benefits in this Asian population. Race, worry about contracting cancer, psychological barriers, and cues from the doctor and a public talk on CRC were associated with screening with gender specific differences. Strategies to increase CRC screening uptake should consider gender specific approaches to address psychological barriers and increase disease susceptibility through public health education and active promotion by physicians.

Primary biliary cirrhosis in Singapore: evaluation of demography, prognostic factors and natural course in a multi-ethnic population.

BACKGROUND AND AIM: Primary biliary cirrhosis (PBC) is infrequent in Asians. Among Asian patients with PBC, information on natural course is scarce. The aim of this study was to study the clinical course and prognosticators among Asians with PBC. METHODS: During 1990-2005, patients diagnosed with PBC at the National University Hospital, Singapore, constituted the retrospective cohort. Their demographic characteristics were evaluated. To evaluate the prognostic factors and natural course, two outcome measures were assessed: hepatic decompensation and death or liver transplant. Multivariate analysis was undertaken to identify factors associated with hepatic decompensation and terminal event (death or liver transplantation). RESULTS: Thirty-four PBC patients aged 56.8 +/- 1.8 years (mean +/- SEM) of whom 32 (94%) were women were included. Thirty-two (94%) of them were of Chinese origin. At presentation, 18 (53%) were symptomatic in the form of jaundice (n = 9, 26.5%), pruritus (n = 6, 17.6%) and fatigue (n = 5, 14.7%). During 4.80 +/- 0.7 (range 0.02-15.03) years follow up, 6/16 (37.5%) asymptomatic patients developed symptoms. After 5 years, 17.6% (n = 6) and 8.8% (n = 3) had hepatic decompensation and terminal event, respectively. Sicca syndrome was present in 26% (n = 9) of patients. Multivariate analysis revealed that serum bilirubin level at presentation was the sole determinant of decompensation. Rate of change of laboratory indices did not predict either event. CONCLUSION: In Singapore, Chinese women constitute most of the PBC patients. Elevated serum bilirubin level at presentation was the sole predictive marker associated with dismal outcome.

Living donor liver transplantation for hepatocellular carcinoma: a single centre experience.

BACKGROUND: The indications of liver transplantation in hepatocellular carcinoma (HCC) are evolving. With the advent of living donor liver transplantation (LDLT), there is a renewed interest in this procedure for tumors beyond the standard Milan criteria. METHODS: We retrospectively analyzed the outcome of 28 patients who underwent LDLT for HCC in one institution. Survival analysis was done using the Kaplan-Meier method. RESULTS: Of the 28 patients, 9, 12 and 7 had Child's A, B and C cirrhosis respectively; 26 (93%) had underlying hepatitis B or C. Nineteen patients (68%) had tumors exceeding the Milan criteria. Postoperative (within 90 days) mortality and morbidity rates were 2/28 (7%) and 7/28 (25%) respectively. The actuarial overall 1-year, 2-year and 3-year survival rates were 76%, 76% and 51%, respectively. The actuarial 1-year, 2-year and 3-year recurrence free survival rates (computed by censoring the data of patients who died of causes other than HCC recurrence) were 88%, 82% and 70%, respectively. Although the survival rates were better for tumors within the Milan criteria than those exceeding them, the difference was not significant. CONCLUSIONS: LDLT is an effective modality in the treatment of HCC in patients with liver cirrhosis. It may also provide an opportunity for potential cure to patients with tumors beyond Milan criteria.

Should non-expert clinician examiners be used in objective structured assessment of communication skills among final year medical undergraduates?

BACKGROUND: Adoption of the objective structured clinical examination may be hindered by shortages of clinicians within a specialty. Clinicians from other specialties should be considered as alternative, non-expert examiners. AIMS: We assessed the inter-rater agreement between expert and non-expert clinician examiners in an integrated objective structured clinical examination for final year medical undergraduates. METHODS: Pairs of expert and non-expert clinician examiners used a rating checklist to assess students in 8 oral communication stations, representing commonly encountered scenarios from medicine, paediatrics, and surgery. These included breaking bad news, managing an angry relative, taking consent for lumbar puncture; and advising a mother on asthma and febrile fits, and an adult on medication use, lifestyle changes and post-suture care of a wound. 439 students participated in the OSCE (206 in 2005, 233 in 2006). RESULTS: There was good to very good agreement (intraclass coefficient: 0.57-0.79) between expert and non-expert clinician examiners, with 5 out of 8 stations having intraclass coefficients > or =0.70. Variation between paired examiners within stations contributed the lowest variance to student scores. CONCLUSION: These findings support the use of clinicians from other specialties, as 'non-expert' examiners, to assess communication skills, using a standardized checklist, thereby reducing the demand on clinicians' time.

Public misperceptions about transmission of hepatitis B virus in Singapore.

INTRODUCTION: Hepatitis B virus (HBV) infection is endemic in Asia. Good public knowledge on disease transmission is one way of controlling spread of HBV. We aimed to study the general knowledge on HBV among the general public in Singapore, which is moderately prevalent with HBV. MATERIALS AND METHODS: Before conducting a public education seminar on liver diseases, a 16-point questionnaire survey was conducted among the participants. Misperceptions (if any) were identified, and factors associated with knowledge score were analysed by multivariate analysis. RESULTS: One hundred and ninety-two subjects completed the questionnaire. The mean age was 52 years, 78 (41%) were male, 183 (95%) were Chinese, 17 (9%) were known hepatitis B carriers and 73 (38%) had completed college education. The mean knowledge score was 10.7 (out of a maximum of 16). Most misperceptions were in the category of HBV transmission. At multivariate analysis, having college education was the only independent factor associated with a high knowledge score. CONCLUSION: Although HBV infection is moderately prevalent in Singapore, many misperceptions existed among the general public, especially on the mode of transmission. Better education was related to better knowledge of HBV. Further public education should be targeted to clear the misperceptions identified, and be specifically targeted to the less educated.

Impact of new legislation on presumed consent on organ donation on liver transplant in Singapore: a preliminary analysis.

Demand for the liver organ for transplantation vastly exceeded the availability of deceased donor organs. A new law, the revised Human Organ Transplant Act (HOTA), was implemented in Singapore in July 2004, which allowed for recovering four organs, including liver, for transplant unless the deceased give objection prior to their demise. We set to study the impact of the revised legislation by comparing the number of potential suitable donors, liver recovery surgery, and liver transplants two years before and one year after the implementation. There was no change in the number of suitable donors, but there was an increase in the number of liver recovery surgeries and liver transplantation, and a lower refusal rate among suitable donors. Although the revised legislation helped improve the availability of deceased donor organs moderately, other nonlegislative, supplementary measures are needed to further improve the low organ donation rate.

A bolt out of the blue: a case of unexpected acute liver failure.

INTRODUCTION: We describe an unusual case of acute hepatitis leading rapidly to acute liver failure. CLINICAL PICTURE: Our patient had known chronic hepatitis B with a regenerating nodule confirmed on imaging and histology. He was admitted initially for abdominal discomfort after a trip to China, and investigations showed acute hepatitis with alanine transaminase (ALT) and aspartate transaminase (AST) at 678 and 557 U/L, respectively. Initial differential diagnoses were acute exacerbations of chronic hepatitis B, and viral hepatitis A or E. However, acute Budd- Chiari syndrome was diagnosed on computed tomography (CT) scan of the abdomen, which showed extensive thrombosis of the hepatic vein, all the intrahepatic branches, inferior vena cava, up to the right atrium. TREATMENT: Due to the extensive nature of the thrombus, radiological or surgical intervention could not be performed. OUTCOME: The patient was managed conservatively but progressed rapidly and died of acute liver failure 16 days after presentation. CONCLUSION: Our case highlights the rapidity of progression of acute Budd-Chiari syndrome. Diagnosis and management of Budd-Chiari syndrome are discussed.

Post-metallic stent placement bleeding caused by stent-induced ulcers.

Placement of self-expandable metal stents (SEMS) is an effective mode of palliative treatment for patients with malignant gastrointestinal obstruction. Gastrointestinal mucosal bleeding complicates about 5% of placement of SEMS but is not well described. We report three cases of gastrointestinal bleeding post-SEMS placement and suggest that bleeding is caused by direct mucosal infringement by the sharp edges of the ends of the stents.

Outcome of lamivudine-resistant hepatitis B virus is generally benign except in cirrhotics.

AIM: We set to determine factors that determine clinical severity after the development of resistance. METHODS: Thirty-five Asian patients with genotypic lamivudine resistance were analyzed in three groups: 13/35 (37%) were non-cirrhotics with normal pre-treatment ALT (Group IA), 12/35 (34%) were non-cirrhotics with elevated pre-treatment ALT (Group IB), and 10/35 (29%) were cirrhotics (Group II). Patients were followed for a median of 98 wk (range 26-220) after the emergence of genotypic resistance. RESULTS: Group IA patients tended to retain normal ALT. Group IB patients showed initial improvement of ALT with lamivudine but 9/12 patients (75%) developed abnormal ALT subsequently. On follow-up however, this persisted in only 33%. Group II patients also showed improvement while on treatment, but they deteriorated with the emergence of resistance with 30% death from decompensated liver disease. Pretreatment ALT levels and CPT score (in the cirrhotic group) were predictive of clinical resistance and correlated with peak ALT levels and CPT score. CONCLUSION: The phenotype of lamivudine-resistant HBV correlated with the pretreatment phenotype. The clinical course was generally benign in non-cirrhotics. However, cirrhotics had a high risk of progression and death (30%) with the development of lamivudine resistance.

Misperceptions among patients with chronic hepatitis B in Singapore.

AIM: To identify the misperceptions among CHB patients, as well as to determine the factors associated with better knowledge. METHODS: A telephone interview was conducted on 192 adult CHB patients, who earlier responded to an advertisement for free screening. The questionnaire included items about socio-demographic factors and a 14-item quiz on knowledge of general aspects, transmission, and management of HBV infection. RESULTS: The mean knowledge score on HBV was 10.4/14. Common misperceptions included availability of treatment for HBV infection and early liver cancer, as well as on transmission. Having completed tertiary education was the only independent factor associated with a high knowledge score, after controlling other demographic factors. CONCLUSION: More educational efforts should be focused on patients' misperceptions and target the less educated HBV carriers.

Remember to crush the tablets after esophageal stent insertion.

The main mode of palliation for inoperable esophageal cancer is by insertion of expandable metallic stents. While major complications include occlusion by tumor ingrowth and migration, impaction by food has been reported in as many as 10% of cases. Although patients are routinely instructed to follow a soft and finely minced diet after insertion of esophageal stents, stent blockage can still occur if patients swallow large-sized tablets. We report a case of stent blockage by 2 large-sized tablets, about which the endoscopist did not forewarn the patient or his family. The tablets were eventually dislodged easily through a repeat endoscopy. We caution about the possibility of such complication after esophageal stenting. We recommend inspection of patients' medication before the stenting procedure as well as instructing patients, their family, and care providers to crush their large-sized tablets before consumption.

Clinical significance of hepatitis B virus genotypes, variants, and mutants.

Emerging evidence suggests that hepatitis B virus (HBV) genotypes may influence the rate of spontaneous and interferon-induced hepatitis B e antigen (HBeAg) seroconversion as well as the natural history of liver disease. In contrast, the dinical significance of precore and core promoter variants associated with HBeAg negative liver disease is less certain in light of the many competing host and virologic factors noted in reported studies. HBV surface mutants are primarily associated with prior vaccine or hepatitis B immune globulin exposure and do not appear to have untoward virulence or association with occult HBV infection. Polymerase mutants with reduced drug sensitivity and phenotypic resistance are commonly detected in patients receiving prolonged antiviral therapy and have a variable impact on disease outcomes. The introduction of additional nucleoside/nucleotide analog agents will likely lead to the development of further unique polymerase mutants with varying pathogenicity and cross-resistance to existing drugs.

Treatment of hepatitis B.

Chronic hepatitis B virus (HBV) infection affects approximately 350 million people worldwide. Treatment of chronic hepatitis B is aimed at sustained suppression of HBV replication and remission of liver disease. Currently, antiviral treatment is indicated for hepatitis B e antigen (HBeAg)-positive patients in the immune clearance phase, and for HBeAg-negative patients with evidence of active liver disease and continued high levels of HBV replication. Treatment is not recommended for patients in the immune tolerance phase or the inactive carrier state, due to lack of efficacy of current treatment. This review updates safety and efficacy data of interferon alpha and lamivudine in the treatment of chronic hepatitis B. Management strategies in different clinical scenarios and future treatments are also discussed.

Esophageal intubation with duodenoscope in the presence of pharyngeal pouch by a guidewire and catheter-guided technique.

Esophageal perforation can occur during blind intubation with a side-viewing duodenoscope during endoscopic retrograde cholangiopancreatogram (ERCP) in patients with pharyngeal or esophageal anomalies. We describe a case of difficult intubation during an ERCP due to an asymptomatic and unsuspected pharyngeal pouch (Zenker's diverticulum). The side-viewing duodenoscope was withdrawn once resistance was encountered during intubation, and a forward-viewing gastroscope was inserted carefully under direct vision to evaluate the upper esophagus. After the diagnosis was made, intubation of the duodenoscope was performed by exchanging scopes over a guidewire. Subsequent ERCP with sphincterectomy and stone removal was uneventful. We caution that a side-viewing duodenoscope should be withdrawn once resistance is encountered during blind intubation during ERCP. Our technique minimizes patient discomfort and is rapid and easy to perform. In addition, no extra device such as an overtube is required.

Modified rendezvous technique in management of biliary leak in right lobe live donor liver transplant recipients.

Biliary complication is the Achilles' heel for live donor liver transplant. Bile leak is particularly difficult to manage as the anastomotic site was often angled acutely. We described a patient with bile leak managed by a modified rendezvous technique whereby the endoscopist and radiologist work simultaneously under fluoroscopy. Unlike the traditionally described rendezvous technique where the grasping of guidewire occurred at the duodenum, the grasping of guidewire occurred at the biloma in this modified technique. Insertion of biliary stent could then be performed over the guidewire through the duodenoscope. The bile leak resolved after keeping the biliary stents in situ for 12 months.