Facilitators of and barriers to high-resolution anoscopy adherence among men who have sex with men: a qualitative study.

Background Anal cancer is a rare malignancy that disproportionately affects men who have sex with men (MSM) and HIV-infected people. Anal cancer is associated with human papillomavirus (HPV) in upward of 90% of cases and is preceded by pre-cancerous changes in cells of the anal canal. High-resolution anoscopy (HRA) is used for the detection, treatment and continued monitoring of anal dysplasia. Practice guidelines regarding anal cancer prevention vary by jurisdiction and institution, and patient engagement is low for high-risk populations such as MSM. The purpose of this study is to characterise perceptions among MSM of barriers to and facilitators of their adherence to HRA follow-up recommendations. METHODS: Surveys and in-person focus groups with MSM who were either adherent or non-adherent to HRA follow-up recommendations at a Federally Qualified Health Centre in Boston, MA, which specialises in sexual and gender minority care, were conducted. Facilitators of and barriers to follow-up were identified by deductive content analysis. RESULTS: Focus group participants identified the following barriers to and facilitators of HRA follow up: (1) patient-level beliefs about HPV-related disease or HRA, ability to engage in care, internalised stigma and physical discomfort; (2) provider-level knowledge and expertise, communication skills and relationship-building with patient; and (3) systems-level societal stigma and healthcare system inefficiencies. CONCLUSIONS: Reinforcing facilitators of and reducing barriers to HRA follow up may improve adherence among MSM. This includes improvements to: patient education, provider training to increase knowledge and cultural sensitivity, public awareness about HPV-related anal cancer, physical discomfort associated with HRA and systems inefficiencies.

Endoscopic transanal resection provides palliation equivalent to transabdominal resection in patients with metastatic rectal cancer.

Patients with metastatic rectal cancer precluding curative low anterior resection (LAR) or abdominoperineal resection (APR) can require palliation for impending obstruction. LAR or APR is frequently not optimal because of the associated operative morbidity. Lesser procedures such as diverting colostomy require patients to live with a permanent stoma. Endoscopic transanal resection (ETAR) has been used for excision of rectal lesions. To determine whether ETAR provides palliation equivalent to LAR or APR, we reviewed the outcomes of 49 patients with rectal adenocarcinoma and unresectable liver metastases who required palliative intervention between January 1989 and July 1996. Of these 49 patients, 24 underwent ETAR; the intraluminal tumor was resected using the urologic resectoscope to achieve a hemostatic, patent lumen. The outcomes of these patients were compared to those of the other 25 patients who had palliative LAR, APR, or a Hartmann procedure during the same period. The median distance of the tumors from the anal verge was similar (5 cm; range 1 to 15 cm). ETAR patients had a higher percentage of poorly differentiated tumors (35% vs. 6%, P = 0.034) and higher preoperative alkaline phosphatase values (478 +/- 75 mg/dl vs. 231 +/- 24 mg/dl; P < 0.015), suggesting more aggressive disease and greater hepatic tumor burden, respectively. Despite these differences, overall survival and time spent outside the hospital were similar in the two groups. The median number of debulking procedures required in the 24 ETAR patients was two (range 1 to 17). Resections in the 25 LAR/APR patients included LAR in 20, APR in two, and Hartmann procedures in three. There was a trend toward more stomas in the LAR/APR group (28% vs. 17%). More important, morbidity was significantly higher in the LAR/APR patients (24% vs. 4%; P = 0.049). In conclusion, ETAR is a safe alternative for the palliation of incurable rectal tumors. Compared to transabdominal resection, ETAR provides equivalent palliation as measured by survival and proportion of the patient's life spent outside the hospital, with a lower stoma rate and significantly less morbidity. Therefore, in select patients with metastatic rectal cancer, ETAR is an important palliative option.

Anxiety reduction in children receiving medical care: developmental considerations.

The present investigation examined the importance of considering age-related conceptual abilities when designing preparation interventions for hospitalization and medical procedures. Forty-eight children, ages 3-5 years and 7-10 years, viewed videotaped information about an upcoming medical procedure. The children were assigned to one of three treatment conditions: control, developmentally appropriate information, developmentally advanced information. Results suggest that information which is designed to match the age-related conceptual abilities of the recipient more effectively reduces anxiety and increases cooperation. Implications for future research evaluating efficacy of preparation strategies are noted.

[Psychological aspects of the preparation and performance of endoscopies in children and adolescents]. / Psychische Aspekte bei der Vorbereitung und Durchführung von Endoskopien bei Kindern und Jugendlichen.

Individual observations lead to the realisation that during endoscopy children may develop such a degree of seemingly unexplainable anxiety that the performance of the examination is considerably prejudiced. We therefore examined 39 children systematically, evaluating them according to fearsome products of their imagination on the one hand and real or warranted anxiety on the other. Adjusted to age the children were tested using drawings, projectional tests and role-playing in addition to interviewing, sometimes of their parents as well. The most prominent expressions of anxiety in conjunction with endoscopy were fear of suffocation; fear of damage to internal organs and, in girls, fear of lesions to a "baby inside". In adolescents problems with prudery became evident. On the basis of our experience we developed a systematic model of psychological preparation for endoscopic examinations.