Computer-Aided Detection Improves Adenomas per Colonoscopy for Screening and Surveillance Colonoscopy: A Randomized Trial.

BACKGROUND & AIMS: Colonoscopy for colorectal cancer screening is endoscopist dependent, and colonoscopy quality improvement programs aim to improve efficacy. This study evaluated the clinical benefit and safety of using a computer-aided detection (CADe) device in colonoscopy procedures. METHODS: This randomized study prospectively evaluated the use of a CADe device at 5 academic and community centers by US board-certified gastroenterologists (n = 22). Participants aged ≥40 scheduled for screening or surveillance (≥3 years) colonoscopy were included; exclusion criteria included incomplete procedure, diagnostic indication, inflammatory bowel disease, and familial adenomatous polyposis. Patients were randomized by endoscopist to the standard or CADe colonoscopy arm using computer-generated, random-block method. The 2 primary endpoints were adenomas per colonoscopy (APC), the total number of adenomas resected divided by the total number of colonoscopies; and true histology rate (THR), the proportion of resections with clinically significant histology divided by the total number of polyp resections. The primary analysis used a modified intention-to-treat approach. RESULTS: Between January and September 2021, 1440 participants were enrolled to be randomized. After exclusion of participants who did not meet the eligibility criteria, 677 in the standard arm and 682 in the CADe arm were included in a modified intention-to-treat analysis. APC increased significantly with use of the CADe device (standard vs CADe: 0.83 vs 1.05, P = .002; total number of adenomas, 562 vs 719). There was no decrease in THR with use of the CADe device (standard vs CADe: 71.7% vs 67.4%, P for noninferiority < .001; total number of non-neoplastic lesions, 284 vs 375). Adenoma detection rate was 43.9% and 47.8% in the standard and CADe arms, respectively (P = .065). CONCLUSIONS: For experienced endoscopists performing screening and surveillance colonoscopies in the United States, the CADe device statistically improved overall adenoma detection (APC) without a concomitant increase in resection of non-neoplastic lesions (THR). CLINICALTRIALS: gov registration: NCT04754347.

A faculty development program to train tutors to be discussion leaders rather than facilitators.

PURPOSE: During 2003, 2004, and 2005, the role of 70 tutors was changed from that of facilitator to discussion leader, in a preclinical PBL learning course, Gastrointestinal Pathophysiology, by use of three key business school teaching strategies: questions, summaries, and schematics. The purpose of this study was to learn what difference this new approach made. METHOD: During each of the three study years, 171 (2003), 167 (2004), and 170 (2005) students were given Likert-scale attitudinal questionnaires to rate whether their tutors encouraged student direction of the tutorials and whether the summaries and closure schematics benefited their learning. Students' overall course evaluations and mean USMLE scores were quantitatively analyzed, pre- and postintervention. A variety of statistical tests were used to assess the statistical significance of means at the confidence level of .05. RESULTS: In the third year of the program, student ratings indicated that their tutors were significantly better at encouraging student direction of the tutorials than in the first year (P < .05). The students reported that the tutorial made a more important contribution to their learning (P < .05), and the course objectives were better stated (P = .038) and better met (P = .007). Overall satisfaction with the course also improved significantly (P = .006). Part I gastrointestinal system mean scores of the USMLE showed a statistically significant increase in 2005 compared with 2001 or 2002. CONCLUSIONS: The tutor as a discussion leader who questions, summarizes, and uses schematics to illustrate concepts had a significant and positive impact on learning in tutorials, achieving course objectives, improving overall course satisfaction, and increasing a standardized national exam's mean score.

Body-mass index and symptoms of gastroesophageal reflux in women.

BACKGROUND: Overweight and obese persons are at increased risk for gastroesophageal reflux disease. An association between body-mass index (BMI)--the weight in kilograms divided by the square of the height in meters - and symptoms of gastroesophageal reflux disease in persons of normal weight has not been demonstrated. METHODS: In 2000, we used a supplemental questionnaire to determine the frequency, severity, and duration of symptoms of gastroesophageal reflux disease among randomly selected participants in the Nurses' Health Study. After categorizing women according to BMI as measured in 1998, we used logistic-regression models to study the association between BMI and symptoms of gastroesophageal reflux disease. RESULTS: Of 10,545 women who completed the questionnaire (response rate, 86 percent), 2310 (22 percent) reported having symptoms at least once a week, and 3419 (55 percent of those who had any symptoms) described their symptoms as moderate in severity. We observed a dose-dependent relationship between increasing BMI and frequent reflux symptoms (multivariate P for trend <0.001). As compared with women who had a BMI of 20.0 to 22.4, the multivariate odds ratios for frequent symptoms were 0.67 (95 percent confidence interval, 0.48 to 0.93) for a BMI of less than 20.0, 1.38 (95 percent confidence interval, 1.13 to 1.67) for a BMI of 22.5 to 24.9, 2.20 (95 percent confidence interval, 1.81 to 2.66) for a BMI of 25.0 to 27.4, 2.43 (95 percent confidence interval, 1.96 to 3.01) for a BMI of 27.5 to 29.9, 2.92 (95 percent confidence interval, 2.35 to 3.62) for a BMI of 30.0 to 34.9, and 2.93 (95 percent confidence interval, 2.24 to 3.85) for a BMI of 35.0 or more. Even in women with a normal baseline BMI, an increase in BMI of more than 3.5, as compared with no weight changes, was associated with an increased risk of frequent symptoms of reflux (odds ratio, 2.80; 95 percent confidence interval, 1.63 to 4.82). CONCLUSIONS: BMI is associated with symptoms of gastroesophageal reflux disease in both normal-weight and overweight women. Even moderate weight gain among persons of normal weight may cause or exacerbate symptoms of reflux.

Prospective study of postmenopausal hormone use and newly diagnosed asthma and chronic obstructive pulmonary disease.

BACKGROUND: Female reproductive hormones appear to influence asthma, although data are conflicting, and may modulate development of chronic obstructive pulmonary disease (COPD). Therefore, in a prospective cohort study, we evaluated whether postmenopausal hormone use was associated with an increased rate of newly diagnosed asthma and, separately, newly diagnosed COPD. METHODS: Postmenopausal hormone use was assessed by questionnaire biennially from 1976 onward. New physician diagnoses of asthma or COPD were reported on questionnaires from 1988 to 1996 and confirmed in 1998 using supplementary questionnaires. Grades of diagnostic certainty were established from reports of medication use and pulmonary function using validated definitions. RESULTS: During 546259 person-years of follow-up, current use of estrogen alone was associated with an increased rate of asthma (multivariate rate ratio, 2.29; 95% confidence interval [CI], 1.59-3.29) compared with those who never used hormones. Current users of estrogen plus progestin had a similarly increased rate of newly diagnosed asthma. Rate ratios increased with certainty of diagnosis of asthma. In contrast, rates of newly diagnosed COPD were the same among hormone users and nonusers (multivariate rate ratio, 1.05; 95% CI, 0.80-1.37). CONCLUSIONS: Postmenopausal hormone use was associated with an increased rate of newly diagnosed asthma but not newly diagnosed COPD. Female reproductive hormones may contribute to the onset of asthma among adult women, but do not appear to hasten the development of COPD.

Prospective study of acetaminophen use and newly diagnosed asthma among women.

Acetaminophen decreases glutathione levels in the lung, which may predispose to oxidative injury and bronchospasm. Acetaminophen use has been associated with asthma in cross-sectional studies and a birth cohort. We hypothesized that acetaminophen use would be associated with newly diagnosed adult-onset asthma in the Nurses' Health Study, a prospective cohort study of 121,700 women. Participants were first asked about frequency of acetaminophen use in 1990. Cases with asthma were defined as those with a new physician diagnosis of asthma between 1990 and 1996 plus reiteration of the diagnosis and controller medication use. Proportional hazard models included age, race, socioeconomic status, body mass index, smoking, other analgesic use, and postmenopausal hormone use. During 352,719 person-years of follow-up, 346 participants reported a new physician diagnosis of asthma meeting diagnostic criteria. Increasing frequency of acetaminophen use was positively associated with newly diagnosed asthma (p for trend = 0.006). The multivariate rate ratio for asthma for participants who received acetaminophen for more than 14 days per month was 1.63 (95% confidence interval, 1.11-2.39) compared with nonusers. It would be premature to recommend acetaminophen avoidance for patients with asthma, but further research on pulmonary responses to acetaminophen is necessary to confirm or refute these findings and to identify subgroups whose asthma may be modified by acetaminophen.

Irritable bowel syndrome: evaluation and treatment.

Irritable bowel syndrome is a common gastrointestinal disorder characterized by abdominal pain, bloating, and disturbed defecation in the absence of other medical conditions with similar presentations. Because physical findings and currently available diagnostic tests lack sufficient specificity for clinical use, the diagnosis of IBS is based on characteristic symptoms as outlined in several symptom-based criteria for IBS. When used in combination with a detailed history, physical examination, and limited diagnostic testing, these criteria are a valid method of diagnosing IBS. Once a confident diagnosis of IBS has been made, treatment of IBS should be based on the predominant symptom while taking into account the severity of symptoms and the degree of functional impairment both physically and psychologically. Most patients with IBS have mild symptoms and education, reassurance, dietary and lifestyle changes, and a therapeutic physician-patient relationship form the backbone of treatment. A smaller number of patients have moderate symptoms, which are typically intermittent, but may at times interrupt their normal activities. In addition to dietary and lifestyle modifications, pharmacologic intervention based on the predominant symptom (diarrhea, constipation, or pain) may be used to relieve symptoms. Finally, a small subset of patients has severe or intractable symptoms. These patients, often seen in tertiary referral centers, often have constant pain symptoms and psychosocial impairments. A multidisciplinary approach including pharmacologic treatments, psychologic treatments, and possibly a mental health or pain center involvement may be beneficial.

Patient factors and medication guideline adherence among older women with asthma.

BACKGROUND: Asthma guidelines are well established but often followed poorly. Determinants of adherence among older persons may differ from younger persons and have not been well characterized. OBJECTIVES: To assess adherence to asthma medication guidelines among older women with asthma and evaluate predictors of adherence with emphasis on asthma characteristics, comorbid medical conditions, work-related factors, social supports, caregiving, and emotional well-being. METHODS: We assessed adherence to the National Asthma Education and Prevention Program medication guidelines among participants in the Nurses' Health Study who reported a physician diagnosis of asthma and reconfirmed the diagnosis on a separate questionnaire, excluding those with chronic obstructive pulmonary disease. RESULTS: Among 121 700 participants in the Nurses' Health Study, 5107 reported physician-diagnosed asthma meeting inclusion criteria. Mean +/- SD age was 63 +/- 7 years in 1998. Adherence with asthma medication guidelines was 57% for mild persistent, 55% for moderate persistent, and 32% for severe persistent asthma (P =.001). In multivariate analysis, nonadherence was associated with severe asthma, increasing age, lower socioeconomic status, current smoking, earlier onset of asthma, and number of comorbid medical conditions. Measures of social isolation, caregiving, and emotional well-being were not associated with nonadherence. CONCLUSIONS: Asthma is undertreated among older women, even those who are health care professionals. Women with advanced age and severe asthma were particularly at risk. Given that the greatest increase in asthma mortality has occurred among older women, further research is needed to examine physician prescribing patterns and patient beliefs in this vulnerable population.