Impact of Expanding Screening Colonoscopy Interval on Providers Choice of Prescribing Colonoscopy for Colorectal Cancer Screening.

GOALS: We investigated if increasing the colonoscopy screening interval from 10 to 15 years would increase provider preferences for colonoscopy as a screening test. We further examined whether having colonoscopy performed at a 15-year interval by an endoscopist with a high adenoma detection rate would influence preferences. BACKGROUND: Colonoscopy is recommended every 10 years in average risk individuals without polyps for colorectal cancer (CRC) screening. The use of a 15-year interval offers substantial protection, increases cost-effectiveness, and might make colonoscopy more attractive to patients and health care providers who order CRC screening tests. STUDY: An anonymous online survey of health care providers across a health care system that serves a single US state and encompasses both academic and community physicians was conducted. Physicians and nurse practitioners in family medicine, obstetrics-gynecology, and internal medicine were included. Providers were asked to indicate their preference for CRC screening tests as a proportion of tests they prescribe among 5 common screening tools. Responses were compared for current colonoscopy screening intervals and if the screening intervals are increased to 15 years. RESULTS: One hundred and twelve (34%) responded of 326 providers. Colonoscopy was the most frequently ordered test for CRC screening. Increasing screening interval from 10 to 15 years increased the choice of colonoscopy from 75.2% to 78.6% ( P =0.003). CONCLUSIONS: Expanding colonoscopy screening interval to 15 years could produce an increase in physicians and nurse practitioners choice of using colonoscopy for CRC screening, but the clinical impact appears minor. Additional surveys of patients and providers are needed.

Crohn's pericarditis identified with point-of-care ultrasonography: A case report.

We report the case of a 71-year-old male with Crohn's disease, shortness of breath, and chest pain that highlights cardiac involvement in inflammatory bowel disease and the role of point-of-care ultrasonography using an alternate cardiac ultrasound window in making the diagnosis of Crohn's pericarditis. The role of ultrasonography in diagnosis and management of inflammatory bowel disease focuses primarily on intestinal pathology. Cardiac involvement is a rare but clinically impactful extraintestinal manifestation, the diagnosis of which benefits from ultrasonography if the clinician performing and interpreting the exam is aware of the possibility and understands the potential value of whole-body ultrasonography as part of a physical exam.

Cancer Palliation: Layered Hypnotic Approaches Mending Symptoms, Minding Hope, and Meaning.

Advanced cancer often produces significant symptoms such as pain, anxiety, insomnia, nausea, and cachexia; many symptoms require medication adjustments in dose and route of administration, and most patients have significant symptom burdens near the end of life. Treatment strategies that integrate mind-body approaches, such as hypnosis, to improve symptoms are increasingly being studied and utilized. The current article addresses the role for adjunctive hypnotic approaches to relieve suffering from pain and other symptoms, while fostering hope, even in the midst of advancing illness, similar to Snyder's (2002) metaphorical painting of "a personal rainbow of the mind" (p. 269). We describe specific clinical indications, technical modifications, and imagistic language used in formulating hypnotic suggestions in the face of illness progression. Furthermore, we specifically describe formulation of layered hypnotic suggestions with intent to intentionally weave suggestions to modify symptoms and link to suggestions to enhance hope and alter time perception. This approach offers the opportunity to transform an experience often defined by its losses to one in which hidden opportunities for growth and change emerge within this transitional life experience.

The digital rectal examination: a multicenter survey of physicians' and students' perceptions and practice patterns.

OBJECTIVES: The digital rectal examination (DRE) may be underutilized. We assessed the frequency of DREs among a variety of providers and explored factors affecting its performance and utilization. METHODS: A total of 652 faculty, fellows, medical residents, and final-year medical students completed a questionnaire about their use of DREs. RESULTS: On average, 41 DREs per year were performed. The yearly number of examinations was associated with years of experience and specialty type. Patient refusal rates were lowest among gastroenterology (GI) faculty and highest among primary-care doctors. Refusal rates were negatively correlated with comfort level of the physician in performing a DRE. More gastroenterologists used sophisticated methods to detect anorectal conditions, and gastroenterologists were more confident in diagnosing them. Confidence in making a diagnosis with a DRE was strongly associated with the number of DREs performed annually. CONCLUSIONS: The higher frequencies of performing a DRE, lower refusal rate, degree of comfort, diagnostic confidence, and training adequacy were directly related to level of experience with the examination. Training in DRE technique has diminished and may be lost. The DRE's role in medical school and advanced training curricula needs to be re-established.

Oral ketamine in the palliative care setting: a review of the literature and case report of a patient with neurofibromatosis type 1 and glomus tumor-associated complex regional pain syndrome.

Ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, has been shown to be effective not only for its anesthetic properties but also for the analgesic and opiate-sparing effects. However, data on efficacy and safety of oral ketamine for the treatment of neuropathic or cancer pain syndromes is limited with most of the evidence based on small clinical trials and anecdotal experiences. In this review, we will analyze the clinical data on oral ketamine in the palliative care setting. After an extensive search using five major databases, a total of 19 relevant articles were included. No official clinical guidelines for the use of oral ketamine in this patient population were found. Studies on oral ketamine for cancer and neuropathic pain have shown mixed results which could be partially due to significant differences in hepatic metabolism. In addition, we will include a case report of a 38-year-old female with neurofibromatosis type 1 (NF1) with history of chronic, severe pain in her fingertips secondary to multiple glomus tumors which evolved into CRPS resistant to multiple therapies but responsive to oral ketamine. Based on our experience with oral ketamine, this drug should be administered after an intravenous trial to monitor response and side effects in patients with an adequate functional status. However, patients in the palliative care and hospice setting, especially the one at the end of their lives, may also benefit from oral ketamine even if an intravenous trial is not feasible.

Palliative care outcomes in surgical oncology patients with advanced malignancies: a mixed methods approach.

PURPOSE: To prospectively compare outcomes and processes of hospital-based early palliative care with standard care in surgical oncology patients (N = 152). METHODS: A randomized, mixed methods, longitudinal study evaluated the effectiveness of a hospital-based Pain and Palliative Care Service (PPCS). Interviews were conducted presurgically and at follow-up visits up to 1 year. Primary outcome measures included the Gracely Pain Intensity and Unpleasantness Scales and the Symptom Distress Scale. Qualitative interviews assessed social support, satisfaction with care, and communication with providers. Survival analysis methods explored factors related to treatment crossover and study discontinuation. Models for repeated measures within subjects over time explored treatment and covariate effects on patient-reported pain and symptom distress. RESULTS: None of the estimated differences achieved statistical significance; however, for those who remained on study for 12 months, the PPCS group performed better than their standard of care counterparts. Patients identified consistent communication, emotional support, and pain and symptom management as positive contributions delivered by the PPCS. CONCLUSIONS: It is unclear whether lower pain perceptions despite greater symptom distress were clinically meaningful; however, when coupled with the patients' perceptions of their increased resources and alternatives for pain control, one begins to see the value of an integrated PPCS.

Efficacy and safety of EMR to completely remove Barrett's esophagus: experience in 41 patients.

BACKGROUND: EMR is typically used to remove focal abnormalities of the esophageal mucosa. However, larger areas of Barrett's esophagus (BE) can be resected through side-by-side resections. OBJECTIVE: To assess the efficacy and safety of EMR to completely remove BE. DESIGN: Retrospective, single-center study. SETTING: University of Iowa Hospitals and Clinics. PATIENTS: Between January 2006 and December 2010, 46 patients underwent EMR for complete removal of BE. Three were lost to follow-up, one died of unrelated causes before completion, and one was still undergoing EMR treatment at the conclusion of the study. The remaining 41 patients were included for analysis. The worst histologic grade was low-grade dysplasia in 4 patients, high-grade dysplasia without cancer in 26 patients, and high-grade dysplasia with superficial adenocarcinoma in 11 patients. BE was circumferential in 65.9% of cases, and the mean (± SD) length was 3.3 ± 2.3 cm. INTERVENTION: EMR was performed by using a cap (n = 4), a multiband ligator device (n = 31), or both (n = 6), with a mean (± SD) of 2.4 ± 1.2 sessions per patient. MAIN OUTCOME MEASUREMENTS: Remission rates and complications. RESULTS: Remission of high-grade dysplasia and cancer, all dysplasia, and all BE was achieved in 94.6%, 85.4%, and 78.0%, respectively. Complications included minor bleeding (31.7%), perforations (4.9%), and strictures (43.9%). All complications were managed conservatively. LIMITATIONS: Retrospective design. CONCLUSION: Complete removal of BE with EMR is effective but associated with a high complication rate, which is mainly related to stricture formation. This needs to be considered when choosing between available treatment modalities.

Spiritual well-being in long-term survivors with chronic graft-versus-host disease after hematopoietic stem cell transplantation.

Spiritual well-being (Sp-WB) is a resource that supports adaptation and resilience, strengthening quality of life (QOL) in patients with cancer or other chronic illnesses. However, the relationship between Sp-WB and QOL in patients with chronic graft-versus-host disease (cGVHD) remains unexamined. Fifty-two participants completed the Functional Assessment of Chronic Illness Therapy-Spiritual WellBeing (FACIT-Sp) questionnaire as part of a multidisciplinary study of cGVHD. Sp-WB was generally high. Those with the lowest Sp-WB had a significantly longer time since diagnosis of cGVHD (P = 0.05) than those with higher Sp-WB. There were no associations between Sp-WB and demographics, cGVHD severity, or intensity of immunosuppression. Participants with the lowest Sp-WB reported inferior physical (P = 0.0009), emotional (P = 0.003), social (P = 0.027), and functional well-being (P < 0.0001) as well as lower overall QOL (P < 0.0001) compared with those with higher Sp-WB. They also had inferior QOL relative to population norms. Differences between the group reporting the lowest Sp-WB and those groups who reported the highest Sp-WB scores consistently demonstrated a significant difference for all QOL subscales and for overall QOL. Controlling for physical, emotional, and social well-being, Sp-WB was a significant independent predictor of contentment with QOL. Our results suggest that Sp-WB is an important factor contributing to the QOL of patients with cGVHD. Research is needed to identify factors that diminish Sp-WB and to test interventions designed to strengthen this coping resource in patients experiencing the late effects of treatment.

Implementing electronic health records in the emergency department.

BACKGROUND: The increasing presence of electronic health records (EHRs) in health care presents interesting and unique challenges in the Emergency Department (ED) setting. Unfortunately, scant literature exists addressing the implementation of EHRs in this setting. OBJECTIVES: The authors, both involved in the implementation of such systems at their respective institutions, review the challenges and benefits that exist with such implementation, and the steps that EDs can take to facilitate this process. DISCUSSION: Unlike ambulatory and inpatient settings, where patient volume can be adjusted to help with this transition, EDs are unable to alter their volume and must maximize their efficiency during this process. CONCLUSIONS: Understanding and anticipating the EHR's impact on workflow is critical to successful implementation.

Sleep deprivation is hyperalgesic in patients with gastroesophageal reflux disease.

BACKGROUND & AIMS: Studies have demonstrated that gastroesophageal reflux disease (GERD) can cause sleep deprivation because of nighttime heartburn or short, amnestic arousals during sleep. Sleep deprivation has been associated with reports of increased GERD severity. Our aim was to determine whether sleep deprivation enhances perception of intraesophageal acid in patients with GERD vs healthy controls. METHODS: Ten healthy controls and 10 patients with erosive esophagitis (grades B-D) were included in the study. All subjects were randomized to either sleep deprivation (1 night with /=7 hours sleep/night). Patients crossed over to the other arm after a washout period of 1 week. To ensure proper sleep time, we objectively monitored subjects with an actigraph. The morning after sufficient sleep or sleep deprivation, patients underwent stimulus response functions to esophageal acid perfusion. RESULTS: Ten healthy controls and 10 GERD patients completed all stages of the study. GERD patients demonstrated a significant decrease in lag time to symptom report (91 +/- 21.6 vs 282.7 +/- 67 sec, respectively, P = .02), increase in intensity rating (9.3 +/- 1.4 vs 4.4 +/- 0.9 cm, respectively, P = .02), and increase in acid perfusion sensitivity score (48.3 +/- 8.5 vs 22.7 +/- 4.5 sec x cm/100, respectively, P = .02) after sleep deprivation as compared with nights of good sleep. Normal subjects did not demonstrate any differences in stimulus response functions to acid between sufficient sleep and sleep deprivation (578 +/- 164 vs 493.8 +/- 60.3 sec, 0.3 +/- 0.2 vs 0.45 +/- 0.2 cm, and 0.4 +/- 0.3 vs 2.4 +/- 1.4 sec x cm/100, respectively, all P = NS). CONCLUSIONS: Sleep deprivation is hyperalgesic in patients with GERD and provides a potential mechanism for increase in GERD symptom severity in sleep-deprived patients.

Evaluating an emergency medical services-initiated nontransport system.

OBJECTIVE: To evaluate both factors predicting nontransport and mortality rates in an emergency medical services system with a nontransport policy. METHODS: We reviewed data from 1,581 transported and nontransported patients from October 2001 to July 2003. Patients who refused transport against medical advice were excluded. Extracted data included demographics, run characteristics, chief complaint, and clinical impression. Transported and nontransported patients were compared using Mann-Whitney U or chi-square tests. Logistic regression identified factors predictive of nontransport. A Social Security Death Index search determined 30-day mortality. RESULTS: A total of 1,501 runs involving 1,059 patients were included. Median age was 60 years (range, 0-97 years). A total of 427 (40.4%) were male; 107 (10.2%) were nonwhite. Older patients were more likely to be transported (odds ratio, 1.03; confidence interval, 1.02-1.03). Race, frequency of calls, mutual aid, or time of day did not significantly influence probability of transport. Patients with cardiovascular, respiratory, and gastrointestinal complaints were more likely to be transported than those with other conditions (P < 0.005); patients with endocrine, trauma, and miscellaneous complaints were less likely to be transported (P < 0.003). Patients with renal, obstetrics/gynecology, and hema matology/oncology were complaints all transported. Mortality was 4.9% (confidence interval, 3.9%-6.2%) for transported patients and 1.0% for those not transported (confidence interval, 0.2%-3.7%). CONCLUSIONS: Age is a determinant when deciding on transporting patients. Patients with complaints with potentially higher acuity were transported most often. Only two nontransported patients died within 30 days, although it is unknown whether initial transport would have changed their mortality. Our data suggest that emergency medical services-initiated nontransport is influenced only by age and chief complaint and may not result in significant mortality.