Clinical validation of the European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE) II criteria in an open-access unit: a prospective study.

BACKGROUND AND STUDY AIMS: The European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE I) criteria were recently updated (EPAGE II), but no prospective studies have used these criteria in clinical practice. The aim of the current study was to validate the EPAGE II criteria in an open-access endoscopy unit. PATIENTS AND METHODS: A prospective observational study was conducted in an open-access endoscopy unit at a tertiary care referral center. Consecutive outpatients (n = 1004; mean age 58.9 ±â€†13.1 years; 45 % men) were referred for diagnostic colonoscopy between September 2009 and February 2010. The appropriateness of colonoscopy was assessed based on EPAGE II criteria, and the relationship between appropriateness and both referral doctor and detection of significant lesions was examined. The effectiveness of EPAGE II criteria in assessing appropriateness was measured by means of sensitivity, specificity, and positive and negative predictive values for detecting significant lesions. RESULTS: Colonoscopic cecal intubation was achieved in 956 patients (95.2 %). Most referral doctors were gastroenterologists (58.0 %) and the most common indication was colorectal cancer (CRC) screening (35.2 %). EPAGE II criteria were applicable in 968 patients (96.4 %); of these patients, the indication was appropriate in 778 (80.4 %), inappropriate in 102 (10.5 %), and uncertain in 88 (9.1 %). Patients with appropriate or uncertain indications based on EPAGE II criteria had more relevant endoscopic findings than those with inappropriate indications (38.8 % vs. 24.5 %; OR 1.95, 95 %CI 1.22 - 3.13; P < 0.005). Sensitivity and negative predictive value of EPAGE II criteria for detecting significant lesions were 93.1 % (95 %CI 90 % - 96 %) and 75.5 % (95 %CI 67 % - 84 %), respectively, whereas for advanced neoplastic lesions these values were 98.0 % (95 %CI 95 % - 100 %) and 98.0 % (95 % CI 95 % - 100 %), respectively. Adherence to EPAGE II recommendations was an independent predictor of finding a significant lesion (OR 1.93, 95 %CI 1.20 - 3.11; P = 0.007). CONCLUSIONS: EPAGE II is a simple, valid score for detecting inappropriate colonoscopies in clinical practice.

Public awareness of colorectal cancer and screening in a Spanish population.

OBJECTIVES: To investigate screening intentions and previous uptake of colorectal cancer (CRC) screening tests in a general population in Spain; and to determine knowledge about CRC, risk perceptions, major barriers to screening and perceived benefits of screening. STUDY DESIGN: Cross-sectional study. METHODS: Six hundred consecutive Spanish individuals over 50 years of age completed a questionnaire to determine their screening intentions, previous CRC diagnostic procedures, and knowledge about screening procedures, risk factors for CRC, 5-year prognosis, warning signs and symptoms, incidence, age-related risk and perceived barriers to screening. RESULTS: Although 78.8% of subjects reported that they were willing to participate in CRC screening, only 12% had ever undergone a screening test, and none with screening intention. Awareness of a breast cancer screening test [odds ratio (OR) 1.67, 95% confidence interval (CI) 1.04-2.70; P = 0.035], visiting a general practitioner in the preceding year (OR 3.08, 95% CI 1.86-5.08; P < 0.0001), awareness of risk factors (OR 2.32, 95% CI 1.49-3.61; P < 0.001), awareness of CRC signs or symptoms (OR 1.65, 95% CI 1.03-2.64; P = 0.04) and belief in the efficacy of CRC screening (OR 8.85, 95% CI 1.53-51.3; P = 0.01) were independent predictors for intention to participate in CRC screening. The most common reasons given for refusing screening were 'CRC tests might be dangerous' (28.2%), 'CRC tests might be painful' (17.9%) and 'feeling healthy' (16.2%). CONCLUSION: Although reported willingness to undergo CRC screening was high, CRC knowledge and actual uptake of CRC screening were low. An educational intervention to reduce barriers and increase awareness could improve uptake of CRC screening.

Mismatch repair status in the prediction of benefit from adjuvant fluorouracil chemotherapy in colorectal cancer.

AIM: Some retrospective studies have shown a lack of benefit of 5-fluorouracil (5-FU) adjuvant chemotherapy in patients with mismatch repair (MMR) deficient colorectal cancer. Our aim was to assess if this molecular marker can predict benefit from 5-FU adjuvant chemotherapy. A second objective was to determine if MMR status influences short term survival. METHODS: We included 754 patients with a median follow up of 728.5 days (range 1-1097). A total of 260 patients with stage II or III tumours received 5-FU adjuvant chemotherapy, according to standard clinical criteria and irrespective of their MMR status. A tumour was considered MMR deficient when either BAT-26 showed instability or there was loss of MLH1 or MSH2 protein expression. RESULTS: At the end of the follow up period, 206 patients died and 120 presented with tumour recurrence. Sixty six (8.8%) patients had MMR deficient tumours. There were no significant differences in overall survival (MMR competent 72.1%; MMR deficient 78.8%; p = 0.3) or disease free survival (MMR competent 61.3%; MMR deficient 72.3%; p = 0.08). In patients with stage II and III tumours, benefit from 5-FU adjuvant chemotherapy was restricted to patients with MMR competent tumours (overall survival: chemotherapy 87.1%; non-chemotherapy 73.5%; log rank, p = 0.00001). Patients with MMR deficient tumours did not benefit from adjuvant chemotherapy (overall survival: chemotherapy 89.5%; non-chemotherapy 82.4%; log rank, p = 0.4). CONCLUSIONS: Benefit from 5-FU adjuvant chemotherapy depends on the MMR status of tumours in patients with colorectal cancer. 5-FU adjuvant chemotherapy improves survival in patients with MMR competent tumours but this benefit from chemotherapy cannot be extended to patients with MMR deficient tumours.

[Screening the at-risk population for squamous cell carcinoma of the esophagus]. / Cribado del carcinoma escamoso de esófago en población de riesgo.

Together with adenocarcinoma, epidermoid esophageal carcinoma is the most clinically important neoplasm of the esophagus. Because of the low incidence of epidermoid esophageal carcinoma in the general population, strategies for its early diagnosis are not a priority compared with other neoplasms. However, because survival is low when the disease is diagnosed in symptomatic patients (less than 20% at 5 years), methods for its early diagnosis should be investigated. The use of cytology or Lugol chromoendoscopy in countries with a high incidence of epidermoid carcinoma or in individuals at increased risk (mainly alcoholics and smokers) has allowed early diagnosis and potentially curative treatment, substantially increasing life expectancy in this group of patients. These results should stimulate the evaluation and eventual implementation of programs to achieve early diagnosis and therefore greater survival in patients with epidermoid esophageal carcinoma in Western countries.

Cribado del carcinoma escamoso de esófago en población de riesgo / Screening the at-risk population for squamous cell carcinoma of the esophagus

El carcinoma epidermoide esofágico es, junto con el adenocarcinoma, la neoplasia del esófago de mayor trascendencia clínica. Su baja incidencia en la población general supone que el establecimiento de estrategias de diagnóstico temprano no parezca prioritario, en comparación con otras neoplasias. Sin embargo, la baja supervivencia cuando se diagnostica la enfermedad en pacientes sintomáticos (inferior al 20% a los 5 años) obliga a investigar medidas de diagnóstico temprano. El empleo de la citología o de la cromoendoscopia con Lugol en países con elevada incidencia de carcinoma epidermoide, o en personas de riesgo aumentado (fundamentalmente alcohólicos y fumadores), ha permitido un reconocimento de las lesiones iniciales, su diagnóstico temprano y un tratamiento potencialmente curativo, lo cual ha incrementado de forma sustancial la esperanza de vida en este grupo de pacientes. Tales resultados deben motivar la evaluación y eventual instauración de programas para lograr el diagnóstico temprano y, por tanto, una mayor supervivencia de los pacientes afectados de carcinoma epidermoide esofágico en Occidente

Together with adenocarcinoma, epidermoid esophageal carcinoma is the most clinically important neoplasm of the esophagus. Because of the low incidence of epidermoid esophageal carcinoma in the general population, strategies for its early diagnosis are not a priority compared with other neoplasms. However, because survival is low when the disease is diagnosed in symptomatic patients (less than 20% at 5 years), methods for its early diagnosis should be investigated. The use of cytology or Lugol chromoendoscopy in countries with a high incidence of epidermoid carcinoma or in individuals at increased risk (mainly alcoholics and smokers) has allowed early diagnosis and potentially curative treatment, substantially increasing life expectancy in this group of patients. These results should stimulate the evaluation and eventual implementation of programs to achieve early diagnosis and therefore greater survival in patients with epidermoid esophageal carcinoma in Western countries

[Liver diseases and pregnancy]. / Enfermedades hepáticas y gestación.

The pregnancy determines a deep variation in the human physiology mediated through sexual hormones. These changes can entail the appearance of diseases that affect the liver such as hyperemesis gravidarum, HELLP syndrome, intrahepatic cholestasis of pregnancy and acute fatty liver of pregnancy. The knowledge of the specific features of these diseases is crucial for their prompt recognition, since they are uncommon diseases in the clinical daily setting of the hepatologist. In addition, several preexisting chronic hepatopathies, including the liver post-transplant status, can affect the course of pregnancy and the maternal-fetal health. Understanding the distinct hepatic diseases which develop during pregnancy must be based on the knowledge of the perceptible physiological changes both on physical examination and laboratory tests which occur during the uneventful gestation.