The learning curve to achieve satisfactory completion rates in upper GI endoscopy: an analysis of a national training database.

OBJECTIVE: The aim of this study was to determine the number of OGDs (oesophago-gastro-duodenoscopies) trainees need to perform to acquire competency in terms of successful unassisted completion to the second part of the duodenum 95% of the time. DESIGN: OGD data were retrieved from the trainee e-portfolio developed by the Joint Advisory Group on GI Endoscopy (JAG) in the UK. All trainees were included unless they were known to have a baseline experience of >20 procedures or had submitted data for <20 procedures. The primary outcome measure was OGD completion, defined as passage of the endoscope to the second part of the duodenum without physical assistance. The number of OGDs required to achieve a 95% completion rate was calculated by the moving average method and learning curve cumulative summation (LC-Cusum) analysis. To determine which factors were independently associated with OGD completion, a mixed effects logistic regression model was constructed with OGD completion as the outcome variable. RESULTS: Data were analysed for 1255 trainees over 288 centres, representing 243 555 OGDs. By moving average method, trainees attained a 95% completion rate at 187 procedures. By LC-Cusum analysis, after 200 procedures, >90% trainees had attained a 95% completion rate. Total number of OGDs performed, trainee age and experience in lower GI endoscopy were factors independently associated with OGD completion. CONCLUSIONS: There are limited published data on the OGD learning curve. This is the largest study to date analysing the learning curve for competency acquisition. The JAG competency requirement for 200 procedures appears appropriate.

Definition and taxonomy of interval colorectal cancers: a proposal for standardising nomenclature.

OBJECTIVE: Interval colorectal cancers (interval CRCs), that is, cancers occurring after a negative screening test or examination, are an important indicator of the quality and effectiveness of CRC screening and surveillance. In order to compare incidence rates of interval CRCs across screening programmes, a standardised definition is required. Our goal was to develop an internationally applicable definition and taxonomy for reporting on interval CRCs. DESIGN: Using a modified Delphi process to achieve consensus, the Expert Working Group on interval CRC of the Colorectal Cancer Screening Committee of the World Endoscopy Organization developed a nomenclature for defining and characterising interval CRCs. RESULTS: We define an interval CRC as a "colorectal cancer diagnosed after a screening or surveillance exam in which no cancer is detected, and before the date of the next recommended exam". Guidelines and principles for describing and reporting on interval CRCs are provided, and clinical scenarios to demonstrate the practical application of the nomenclature are presented. CONCLUSIONS: The Working Group on interval CRC of the World Endoscopy Organization endorses adoption of this standardised nomenclature. A standardised nomenclature will facilitate benchmarking and comparison of interval CRC rates across programmes and regions.

Developing a strategy for accreditation of clinical services.

Accreditation is one method of assuring quality. Accreditation requires the setting of standards and the creation of a robust and reliable process for assessing them. Accreditation offers different advantages to different groups, eg quality assurance to commissioners and the boards of provider organisations, confidence and choice for patients, and a quality improvement pathway for services to follow. This paper is focused on service accreditation and it proposes that service accreditation be professionally led.

European guidelines for quality assurance in colorectal cancer screening and diagnosis. First Edition--Colonoscopic surveillance following adenoma removal.

Multidisciplinary, evidence-based guidelines for quality assurance in colorectal cancer screening and diagnosis have been developed by experts in a project coordinated by the International Agency for Research on Cancer. The full guideline document covers the entire process of population-based screening. It consists of 10 chapters and over 250 recommendations, graded according to the strength of the recommendation and the supporting evidence. The 450-page guidelines and the extensive evidence base have been published by the European Commission. The chapter on colonoscopic surveillance following adenoma removal includes 24 graded recommendations. The content of the chapter is presented here to promote international discussion and collaboration by making the principles and standards recommended in the new EU Guidelines known to a wider professional and scientific community. Following these recommendations has the potential to enhance the control of colorectal cancer through improvement in the quality and effectiveness of surveillance and other elements in the screening process, including multi-disciplinary diagnosis and management of the disease.

European guidelines for quality assurance in colorectal cancer screening and diagnosis. First Edition--Quality assurance in endoscopy in colorectal cancer screening and diagnosis.

Multidisciplinary, evidence-based guidelines for quality assurance in colorectal cancer screening and diagnosis have been developed by experts in a project coordinated by the International Agency for Research on Cancer. The full guideline document covers the entire process of population-based screening. It consists of 10 chapters and over 250 recommendations, graded according to the strength of the recommendation and the supporting evidence. The 450-page guidelines and the extensive evidence base have been published by the European Commission. The chapter on quality assurance in endoscopy includes 50 graded recommendations. The content of the chapter is presented here to promote international discussion and collaboration by making the principles and standards recommended in the new EU Guidelines known to a wider professional and scientific community. Following these recommendations has the potential to enhance the control of colorectal cancer through improvement in the quality and effectiveness of endoscopy and other elements in the screening process, including multidisciplinary diagnosis and management of the disease.

Control of downy mildew on grapes in organic viticulture.

Few active substances with fungicide activity can be used in organic farming, above all copper and sulphur. The copper is the only substance that can be used against downy mildew; however, since it causes problems of environmental impact, incompatible with organic farming's objective of environmentally friendly farming, the Commission of the European Communities has fixed a ceiling on use expressed in terms of kilograms of copper per hectare per year (Regulation EC n. 473/2002). In order to identify natural products that are able to carry out an anti-downy mildew activity, and to evaluate the effectiveness of low rate copper formulations that can reduce the quantities of copper compound, four-year experimental trials were carried out in organic vineyards. The trials have been carried out according to the Guidelines EPPO/OEPP PP 1/31 (3). Among the low rate copper formulations, copper hydroxide and copper sulphate have been tested. Among the natural substances alternative to copper formulations we have tested: phytostimulant, homeopathic products, acid clay-based products (bentotamnio), resistance promoters (chitosan and lignosulfonate), plant extracts (orange extract, propolis and equisetum) and potassium bicarbonate. All natural substances, with the exception of plant extracts and potassium bicarbonate, were tested in association with low rate copper formulations. In the trials it has been possible to test the effectiveness of different formulations in condition of high, medium and low pressure of Plasmopara viticola (Berk. et Curt.) Berl. et De Toni. Both the copper compounds and the natural products were able to guarantee a satisfactory protection in condition of low and medium pressure of downy mildew. The trial carried out in 2004 was characterized by high pressure of P. viticola; under this condition only the copper formulations produced a satisfactory protection against downy mildew. However, in 2004, we tested only two products alternative to copper compounds. Further studies are needed to verify if the formulations alternative to copper, that gave good results in condition of low and medium pressure of P. viticola, are able to guarantee a satisfactory protection even in condition of high pressure of downy mildew. We would like to highlight that in the four-years of trials the copper formulations tested always guaranteed a metallic copper quantity under 6 kg/ha that is the maximum limit of use/year imposed by Regulation EC n. 473/2002.

Measuring the meaning of life for patients with incurable cancer: the life evaluation questionnaire (LEQ).

Clinical observation, systematic research and popular anecdote indicate that, when confronted by death, people change the criteria by which they evaluate their lives. Questionnaires used routinely to assess quality of life in people with poor-prognosis cancer tend to be symptom-based and do not assess factors which become important when confronted by fatal illness, such as the meaning of life and the degree to which life has been enriched by the illness. To develop a questionnaire which would be sensitive to these areas, patients with incurable cancer and carers of such patients were interviewed in depth. Responses were reviewed by a panel of patients, clinicians and carers and formed into an inventory which was completed by 200 similar patients. Principal components analysis identified five dimensions: clearer perception of the meaning of life; freedom versus restriction of life; resentment of the illness; contentment with past and present life; past and present social integration. Only the most symptom-oriented scales (freedom, resentment) correlated with the Rotterdam Symptom Checklist. Scale scores showed that younger patients were more resentful of their illness, but also gained a clearer perception of the meaning of life. This questionnaire can evaluate psychological needs of people with incurable cancer which are neglected by existing instruments.

The measurement of beliefs about physical symptoms in English general practice patients.

A way of measuring patients' beliefs about the origin of their symptoms would allow the investigation of important questions concerning the consultation process and its outcome. The purpose of this study was to develop an instrument that could measure the beliefs about symptoms of patients attending their general practitioner and to demonstrate its utility by comparing beliefs about three types of symptom (respiratory, musculoskeletal and gastrointestinal). Interviews of 150 patients generated items for the belief questionnaire which was then completed by a second sample of 406 general practice patients. Principal components analysis of the responses identified eight readily interpretable belief dimensions: stress; lifestyle; wearing out; environment; internal-structural; internal-functional; weak constitution; concern. Scales were constructed to measure each dimension and the symptom groups were compared. Gastrointestinal symptoms were the most likely to be attributed to internal malfunction and to lifestyle or weak constitution. Musculoskeletal symptoms were more likely to be attributed to structural problems caused by the body wearing out and respiratory symptoms, in contrast, to the influence of the environment. Contrary to prediction, attribution to stress was made equally for the different types of symptom. We have devised a questionnaire, valid specifically for general practice patients, which permits the quantification of beliefs in this setting. The questionnaire could be used in future to track how beliefs respond to medical intervention and how, in turn, beliefs influence illness behaviour.

Patients' intentions in primary care: relationship to physical and psychological symptoms, and their perception by general practitioners.

A series of three studies of consecutive primary care patients examined their intentions when visiting a general practitioner (GP). In study 1, a principal, components analysis of responses to a specially-devised symptom check-list was used to form component-based scales on which patients' physical symptoms were scored. Apart from a modest association of cold symptoms with seeking simple explanation, physical symptoms were unrelated to intentions. By contrast, the level of psychological symptoms correlated with the desire for support from the GP. In study 2 this result was replicated and shown to be unaffected by the amount of support which patients already experienced from family and friends. In study 3, GPs were found to be able to detect at better than chance level which patients desired support, but they were insensitive to other intentions. The results indicate that a technique for the quantification of patients' intentions permits the formal investigation of important questions concerning primary care consultations.

The Patient Requests Form: a way of measuring what patients want from their general practitioner.

A consumer-oriented approach to the delivery of health care and an understanding of the processes that influence clinical management decisions require the measurement of what patients seek when they consult their doctor. The present study completed the development of an instrument (the Patient Requests Form) that can quantify the intentions of patients attending their general practitioner. The Patient Requests Form was completed by 410 patients attending two general practices: one in an inner city area, the other in a small town. Principal components analysis revealed that the responses from each sample yielded identical components that described three distinct types of request: (i) for explanation and reassurance, (ii) for emotional support, and (iii) for investigation and treatment. Scales constructed to measure each type of request have high internal consistency while being sufficiently brief to be acceptable to general practice patients. The Patient Requests Form is a novel, convenient method to quantify the intentions of patients when they consult a general practitioner. It permits research into neglected aspects of consultation behaviour, including the factors that influence patients' intentions to seek different kinds of help and GPs' perceptions of these intentions.

General practice patients' beliefs about their symptoms.

BACKGROUND: Patients' beliefs about symptoms are major influences on consultation and its consequences. However, little information is available about the beliefs of patients when they consult their general practitioner (GP). AIM: To describe and quantify the range of beliefs of patients about their symptoms before consultation, and to test the hypothesis that patients who attribute symptoms to stress or lifestyle would expect less benefit than others from physical medicine but more from lifestyle change and emotional support. METHOD: Interviews with 100 patients attending one of two general practices were used to form a questionnaire, which was completed by 406 patients attending one of three general practices in contrasting areas of Greater London. This measured the frequency of specific beliefs about the causes of their symptoms and about effective forms of help. Patients were seen before their consultation. RESULTS: The most common aetiological beliefs concerned stress and lifestyle. In general, the mechanisms underlying symptoms were thought to be disturbances in bodily functioning rather than pathological processes. The most valued form of help was explanation and discussion of symptoms. Nevertheless, about half the patients expected benefit from medication and only slightly fewer from hospital investigation or treatment. Patients who attributed symptoms to stress or lifestyle were no less likely to expect help from medication or specialist referral, but they were more likely to see benefit in explanation and counselling or lifestyle change. CONCLUSIONS: These findings suggest hypotheses for future research into the effects that patients' attributions of their symptoms to stress and lifestyle have on their health care demands, emphasize the importance of routinely assessing patients' beliefs on consulting the GP, and provide information that can help to direct this assessment in the individual case.

Hospital patients who wear tinted spectacles--physical sign of psychoneurosis: a controlled study.

The wearing of tinted spectacles by patients is often said to be a marker of psychopathology but without supportive evidence. To investigate the validity of this observation the personalities of 20 medical hospital patients who wore tinted spectacles were compared, by means of a self-report inventory, with those of 20 controls who were age, sex, and diagnosis matched. There was a significant increase in the level of psychopathology in the tinted spectacle group, both in terms of an index of global psychological distress; the General Severity Index, and nine primary symptom dimensions measured by the inventory.

The action of trimebutine maleate on gastrointestinal motility is mediated by opiate receptors in human subjects.

The effects of trimebutine on interdigestive motor activity of the small intestine and the colon were studied in healthy volunteers. Trimebutine induced in all subjects phase III-like motor complexes, which were similar to spontaneously occurring phase III complexes of the interdigestive cycle in antrum and duodenum. Trimebutine-induced complexes were suppressed by naloxone. Trimebutine and/or naloxone had no consistent effect on interdigestive contractile activity in the colon.

[Thyroid tumors in the mediastinum]. / I tumori tiroidei a sede mediastinica.

The Authors studied 46 cases of thyroid neoplasm, characterized by a mediastinal involvement of different degrees, and analysed the epidemiologic, anatomo-pathological and clinical aspects thereof. Then, they, on the basis of their experience, outlined the formulation of the diagnostic ascertainments and surgical treatment.

A novel method for determining the difficulty of colonoscopic polypectomy.

INTRODUCTION: Endoscopists are now expected to perform polypectomy routinely. Colonic polypectomy varies in difficulty, depending on polyp morphology, size, location and access. The measurement of the degree of difficulty of polypectomy, based on polyp characteristics, has not previously been described. OBJECTIVE: To define the level of difficulty of polypectomy. METHODS: Consensus by nine endoscopists regarding parameters that determine the complexity of a polyp was achieved through the Delphi method. The endoscopists then assigned a polyp complexity level to each possible combination of parameters. A scoring system to measure the difficulty level of a polyp was developed and validated by two different expert endoscopists. RESULTS: Through two Delphi rounds, four factors for determining the complexity of a polypectomy were identified: size (S), morphology (M), site (S) and access (A). A scoring system was established, based on size (1-9 points), morphology (1-3 points), site (1-2 points) and access (1-3 points). Four polyp levels (with increasing level of complexity) were identified based on the range of scores obtained: level I (4-5), level II (6-9), level III (10-12) and level IV (>12). There was a high degree of interrater reliability for the polyp scores (interclass correlation coefficient of 0.93) and levels (κ=0.888). CONCLUSIONS: The scoring system is feasible and reliable. Defining polyp complexity levels may be useful for planning training, competency assessment and certification in colonoscopic polypectomy. This may allow for more efficient service delivery and referral pathways.

Development and roll out of the JETS e-portfolio: a web based electronic portfolio for endoscopists.

The JAG Endoscopy Training System (JETS) e-portfolio was designed to provide an electronic log of endoscopic experience, improve the effectiveness of training, streamline the JAG certification process and support the quality assurance of trainers, units and regional training programmes. It was piloted in 2008 with an 82.6% uptake in trainees offered the system. The system was released in the UK in September 2009. Steady adoption across the UK demonstrates the service finds it a valuable tool. In time it will be the only vehicle through which a trainee can achieve certification through JAG to practise independently.

How to perform a percutaneous liver biopsy.

Liver biopsy is a safe and indispensable tool for the diagnosis and management of many forms of liver disease. Percutaneous techniques are easy to learn and relatively little experience is required to obtain an adequate specimen of liver safely. Most doctors training in general medicine and some training in general surgery and radiology should develop experience with this technique.