A new diprenyl coumarin and alkaloids from the bark of Zanthoxylum dimorphophyllum (Rutaceae).

The alkaloids chelerythrine, norchelerythrine, oxyavicine, canthine-6-one, 4,5-dihydrocanthin-6-one, and gamma-fagarine were isolated from Zanthoxylum dimorphophyllum bark, together with two coumarins, scoparone and dimoxylin. This latter is a novel compound whose structure was elucidated on the basis of its spectral data.

Improved patient care using the A/S/G/E guidelines on quality assurance: a prospective comparative study.

The American Society for Gastrointestinal Endoscopy has promulgated guidelines on quality assurance in gastrointestinal endoscopy. Thorough documentation of endoscopy reports and a peer review process were strongly recommended. We evaluated 1408 dictated endoscopy and colonoscopy reports for deficiency in reference to the guidelines during three periods: 6 months before (group 1), 6 months after the application of the guidelines (group 2), and 5 months of intensive peer review process (group 3). Deficiency was defined as lack of documentation of at least 1 of the 10 parameters that should be included in endoscopy reports according to the guidelines. There was a significant decrease in deficiency rates in groups 2 (91.6%) and 3 (32.7%) compared with group 1 (99.8%) (p less than 0.01). Peer review and direct confrontation of the endoscopists with their deficiencies significantly reduced the use of inappropriate indication for endoscopy (1.5%/group 3 vs. 5.2%/group 1, p less than 0.01). Adherence to the A/S/G/E guidelines on quality assurance improved documentation, decreased inappropriate use of endoscopy, and may thus improve quality of care.

The sentinel hyperplastic polyp: a marker for synchronous neoplasia in the proximal colon.

We prospectively screened 129 asymptomatic subjects (mean age 64 yr) with flexible sigmoidoscopy. Colonoscopy was performed at a later date, regardless of the sigmoidoscopic result. Our intent was 1) to establish the prevalence of proximal neoplasms in patients with and without hyperplastic polyps within reach of the 60-cm sigmoidoscope and 2) to determine whether a distal (sentinel) hyperplastic polyp predicts the presence of synchronous neoplastic polyps higher up in the colon. Our results show that 15% of asymptomatic adult subjects without polyps on sigmoidoscopy have adenomas in proximal colonic segments that can be diagnosed only by colonoscopy. By comparison, proximal neoplasms were detected in 32% (p less than 0.05) and 37% (p less than 0.05) of patients when hyperplastic or adenomatous polyps, respectively, were present on the sigmoidoscopic examination. This finding suggests that a distal (sentinel) hyperplastic polyp by itself may be a marker for neoplastic polyps in proximal colonic segments. Also, the "index" adenoma and "sentinel" hyperplastic polyp may be equivalent for predicting the presence of proximal neoplasms. The observed detection rates for these polyps were both significantly higher than expected when compared to patients who did not have polyps in the distal colon or rectum. If these results can be confirmed by a larger prospective trial, then full colonoscopy for detection of proximal neoplasms may be indicated when either an index adenoma or sentinel hyperplastic polyp is detected by sigmoidoscopy.

Prevalence and malignant potential of colorectal polyps in asymptomatic, average-risk men.

Screening colonoscopy was performed on 119 asymptomatic elderly men with no other risk factors for colonic neoplasms. Ninety adenomas were detected in 49 (41%) subjects. Mean adenoma size was 6.5 mm, with 83 (92%) less than or equal to 10 mm. Forty-nine (54%) adenomas were located proximal to the splenic flexure, and 17 (19%) were classified as tubulovillous or villous. Moderate- to high-grade dysplasia was found in 29 (32%) adenomas and was associated with larger size (p less than 0.0001) and villous architecture (p = 0.0038). Two subjects harbored adenomas with invasive cancer. Seventy-one hyperplastic polyps were found in 40 (34%) subjects. The mean size of hyperplastic polyps was 3.4 mm, and 64 (90%) were located in the left colon. We conclude that, in this population, adenomas are common lesions that are frequently small. However, substantial proportions of these adenomas may be at risk for malignant degeneration due to the presence of villous architecture and higher grades of dysplasia. Because adenomas and hyperplastic polyps are endoscopically indistinguishable, all polyps found at endoscopy should be removed or ablated.