Identifying Gender Barriers for Colorectal Cancer Screening and Assessing the Need for a Multigender Endoscopy Team: A Prospective Multicenter Study.

INTRODUCTION: Gender preferences have been reported as a barrier to colorectal cancer screening, particularly among women. We aim to identify the role of patients' gender preferences for endoscopists and endoscopy team members, with the effect of age-related and regional differences. METHODS: We conducted an anonymous, voluntary survey of all adult outpatients presenting at our endoscopy centers before their procedures. RESULTS: We received 2,138 (1,207 women, 905 men, and 26 undisclosed; 50% urban and 50% rural) completed surveys. The majority of the patients (89%) did not have an endoscopist gender preference, while 8% preferred a same-gender endoscopist, and 2% preferred an opposite gender endoscopist. Among patients who expressed a gender preference, men more commonly preferred a same-gender endoscopist than women (91% vs 67%, P < 0.05). More patients preferred a same-gender endoscopy team member than a same-gender endoscopist (17% vs 8%, P < 0.05), and women more commonly preferred a same-gender endoscopy team member than men (26% vs 6%, P < 0.05). Most patients who expressed same-gender endoscopist preference were between the ages of 50-69 years as compared to other age groups (P < 0.05). Of the urban patients, 9% expressed a same-gender endoscopist preference and 3% expressed an opposite gender preference, compared with 7% and 2% of rural patients (P < 0.05). Among patients with any endoscopist gender preference, rural patients were more willing to wait longer (41% vs 21%, P < 0.05), whereas urban patients were willing to pay more (64% vs 14%, P < 0.05) to have their preferences met. DISCUSSION: Contrary to previous studies, most patients did not have an endoscopist gender preference. Interestingly, men had more same-gender endoscopist preference, whereas women had more same-gender endoscopy team member preference. Age-related and regional differences exist among patients' gender preferences for their endoscopist and endoscopy team member, and addressing these preferences while creating an environment of a multigender endoscopy team may be beneficial in improving colorectal cancer screening.

Predicting the risk of recurrent adenoma and incident colorectal cancer based on findings of the baseline colonoscopy.

OBJECTIVES: The decision tree underlying current practice guidelines for post polypectomy surveillance relies on risk stratification based on predictive attributes gleaned from adenomas removed on screening colonoscopy examination. Our primary aim was to estimate the magnitude of association between baseline adenoma attributes and the risk of adenoma recurrence and invasive colorectal adenocarcinoma (CRC). Our secondary aims were to estimate the adenoma detection rate (ADR) of surveillance compared with screening colonoscopies and describe time trends in preventive colonoscopy utilization. METHODS: We used prospective analyses of retrospectively collected clinical data from electronic health records. A cohort of primary care patients eligible for colorectal cancer screening was assembled encompassing 110,452 subjects, of which 3,300 had adenomas removed on screening examination. Of those patients who had a follow-up surveillance colonoscopy (defined as a patient with a documented adenoma on prior colonoscopy) recorded during the study period, 537 had a recurrent adenoma. RESULTS: Of those recurrent adenomas, 354 had a high-risk attributes. High-risk attributes were described at >3 adenomas, at least one adenoma >10 mm in size, high-grade dysplasia, or villous features. The risk of developing invasive CRC among post polypectomy patients was significantly higher if the baseline adenomas displayed any of the following attributes: more numerous than 3 (4.3-fold higher risk, 95% confidence interval (CI) low, high 1.4, 12.9), larger than 10 mm in size (5.2-fold higher risk, 95% CI low, high 1.8, 15.1), high-grade dysplasia (13.2-fold risk, 95% CI low, high 2.8, 62.1), or villous features (7.4-fold higher risk, 95% CI low, high 2.5, 21.5). These attributes combined added a net value of 22.8% to the probability of correctly predicting CRC. There was a threefold increase in surveillance utilization relative to screening from 2005 to 2011. The ADR of surveillance (34.1%) was 1.5-fold higher than that of screening (23.1%). CONCLUSIONS: These results emphasize the need to mitigate excessive risk by performing timely surveillance colonoscopies in patients with baseline adenomas displaying high-risk attributes as recommended in practice guidelines.

Risk factors for colonoscopic perforation: a population-based study of 80118 cases.

AIM: To assess the incidence and risk factors associated with colonic perforation due to colonoscopy. METHODS: This was a retrospective cross-sectional study. Patients were retrospectively eligible for inclusion if they were 18 years and older and had an inpatient or outpatient colonoscopy procedure code in any facility within the Geisinger Health System during the period from January 1, 2002 to August 25, 2010. Data are presented as median and inter-quartile range, for continuous variables, and as frequency and percentage for categorical variables. Baseline comparisons across those with and without a perforation were made using the two-sample t-test and Pearson's χ² test, as appropriate. RESULTS: A total of 50 perforations were diagnosed out of 80118 colonoscopies, which corresponded to an incidence of 0.06% (95%CI: 0.05-0.08) or a rate of 6.2 per 10000 colonoscopies. All possible risk factors associated with colonic perforation with a P-value < 0.1 were checked for inclusion in a multivariable log-binomial regression model predicting 7-d colonic perforation. The final model resulted in the following risk factors which were significantly associated with risk of colonic perforation: age, gender, body mass index, albumin level, intensive care unit (ICU) patients, inpatient setting, and abdominal pain and Crohn's disease as indications for colonoscopy. CONCLUSION: The cumulative 7 d incidence of colonic perforation in this cohort was 0.06%. Advanced age and female gender were significantly more likely to have perforation. Increasing albumin and BMI resulted in decreased risk of colonic perforation. Having a colonoscopy indication of abdominal pain or Crohn's disease resulted in a higher risk of colonic perforation. Colonoscopies performed in inpatients and particularly the ICU setting had substantially greater odds of perforation. Biopsy and polypectomy did not increase the risk of perforation and only three perforations occurred with screening colonoscopy.

Gastroenterologists and accountable care organizations.

Within the Patient Protection and Affordable Care Act of 2010 is a provision setting up a program for the implementation of accountable care organizations (ACOs). This article explains the proposed ACO model and discusses major implications regarding this model of health care reform including the following: What will it take to implement the program successfully? What are the opportunities for savings under the model? What are the potential downfalls of the program as proposed? What impact would the implementation of an ACO have on the practice of gastroenterology?

Telangiectasia macularis eruptiva perstans, a form of cutaneous mastocytosis, associated with malignant melanoma.

A 62-year-old obese woman presented with a malignant melanoma (Stage la). In addition, she had disseminated telangiectatic macules on both thighs. Intensive rubbing of lesions resulted in wheals. Biopsy revealed increased numbers of mast cells. We diagnosed telangiectasia macularis eruptiva perstans, a rare clinical form of adult maculopapular cutaneous mastocytosis, a group which also includes urticaria pigmentosa. No evidence was found for systemic involvement. Possible associations with malignant tumors and the possible role of c-kit mutations both in development of melanoma and mastocytosis are discussed.

Pharmacokinetics of pimecrolimus, a novel nonsteroid anti-inflammatory drug, after single and multiple oral administration.

OBJECTIVE: To investigate the pharmacokinetics and tolerability of the new nonsteroid anti-inflammatory pimecrolimus (SDZ ASM 981, Elidel) after oral administration. DESIGN: A single-dose, randomised, double-blind, placebo-controlled, dose-rising, parallel-group study in healthy male volunteers, and a multiple-dose, randomised, double-blind, placebo-controlled, dose-rising study in patients with psoriasis. SETTING: One centre in France (single-dose study) and one centre in Austria (multiple-dose study). METHODS: The first study investigated the pharmacokinetics and tolerability of ascending single oral doses of pimecrolimus (5-60mg). The 60mg dose was repeated in the same subjects after a fat-rich breakfast. The second study investigated the pharmacokinetics, tolerability, safety and efficacy of rising oral doses administered once daily (5-20mg) or twice daily (20 and 30mg) for 28 days. Only the pharmacokinetic, safety and tolerability data of this study are presented. OUTCOME MEASURES AND RESULTS: Oral administration of pimecrolimus was well tolerated up to the highest dose (60mg). Pimecrolimus was rapidly absorbed (time to maximum blood concentration 0.7-2 hours). A high-fat meal before drug administration delayed the time to peak concentration. Blood concentrations appear to have a long-terminal half-life (30-40 hours after a single dose in fasted subjects, 50-100 hours after the final dose on day 28 in psoriasis patients). After multiple doses, steady state was attained after 6-13 days. Maximum blood concentrations (C(max)) and exposure (area under the concentration-time curve; AUC) were broadly dose proportional. At the highest dose administered in the multiple-dose study (30mg twice daily), a C(max ) of 54.7 microg/L was measured and an AUC(24) of 589.8 microg.h/L was calculated at steady state (day 13). CONCLUSION: The results support further evaluation of the therapeutic potential of oral pimecrolimus for the treatment of inflammatory diseases.

Hypercalcemia and peptic ulcer disease-related Milk-alkali syndrome.

Milk-alkali syndrome was considered "extinct" by 1985 because of the advent of non-alkaline ulcer medications (ie, histamine-2 receptor blockers and proton pump inhibitors). At that time, it was thought to cause <1% of hypercalcemia, which occurred when one ingested a sufficient quantity of calcium and alkali together. This case emphasizes the importance of considering this syndrome in patients who self-medicate for control of symptoms related to gastroesophageal reflux and peptic ulcer disease and for those using calcium supplementation for prevention or treatment of osteoporosis.

Pimecrolimus identifies a common genomic anti-inflammatory profile, is clinically highly effective in psoriasis and is well tolerated.

The ascomycin macrolactam pimecrolimus is a novel inflammatory cytokine release inhibitor that so far has not been administered systemically to humans. In this phase I/II randomized double-blind, placebo-controlled, multiple rising dose proof of concept study psoriasis patients were treated with oral pimecrolimus or placebo. Gene profiling identified a common genomic profile with a downregulation of genes associated with inflammation but no changes in gene expression linked to drug-related side-effects. A steady state of pimecrolimus was reached after 5-10 d, Cmax, and area under the curve (0-24) was 54.5 ng per ml and 589.9 ng h per ml, respectively, at steady state at the highest dose. There was clear clinical efficacy in patients receiving 20 mg pimecrolimus twice daily and 30 mg twice daily with a reduction of Psoriasis Area and Severity Index by 60% and 75%, respectively. Histopatho logically and immunopathologically there was a reversion of the psoriatic phenotype towards normal. There were no notable clinical, laboratory, kidney function, or immunologic side-effects. We conclude that pimecrolimus taken orally is highly effective in a concentration-dependent manner in patients with psoriasis and on a short-term basis it is well tolerated and this is confirmed by its pharmacogenomic profile. The latter also indicates that pimecrolimus should be equally effective in other inflammatory skin diseases.

Early initiation of enteral feeding after percutaneous endoscopic gastrostomy tube placement.

Enteral feeding through the percutaneous endoscopic gastrostomy (PEG) tube is usually initiated about 12 to 24 hours after insertion of the tube. There have been earlier studies evaluating the efficacy of early initiation of enteral feedings that had encouraging results. However, delayed initiation of feeding following PEG placement continues to be practiced widely. We believe that feeding can be done earlier without any increase in associated morbidity or mortality and with obvious reduction in the need for parenteral nutrition and healthcare costs. We evaluated a protocol to initiate enteral nutrition 4 hours after the PEG tube insertion with subsequent discharge of the outpatients on the same day. We conducted a prospective study to assess the efficacy of early initiation of PEG feeding. We enrolled 77 patients in our study who were having PEG tubes placed for enteral feeding. Only patients who had a PEG placed for gastric venting procedures were excluded from our study. During the course of our study, no patient had to be excluded for the latter reason. Patients were evaluated by the physician performing the procedure, 4 hours after the tube was inserted. Their vital signs were checked, and a thorough abdominal examination was performed. Minimal tenderness around the PEG site was the most frequent finding. Otherwise, all the patients had a benign abdominal examination. The tube was flushed with 60 mL of sterile water. Following the examination, orders were given to restart the feedings. These patients were followed for a 30-day period to evaluate complications associated with PEG tube placement and early initiation of PEG feeding. There was one case of aspiration pneumonia (1.3%) and one death that was attributed to the underlying disease out of our 77 patients. Early initiation of enteral feeding after PEG tube placement can be successfully completed with a systematic protocol and close observation. Not only was this protocol found to be safe, it can also have significant cost savings by eliminating the need for inpatient hospitalization for the procedure.