Coeliac disease screening is suboptimal in a tertiary gastroenterology setting.

BACKGROUND AND AIMS: Coeliac disease (CD) is widely prevalent in North America, but case-finding techniques currently used may not be adequate for patient identification. We aimed to determine the adequacy of CD screening in an academic gastroenterology (GI) practice. METHODS: Consecutive initial visits to a tertiary academic GI practice were surveyed over a 3-month period as a fellow-initiated quality improvement project. All electronic records were reviewed to look for indications for CD screening according to published guidelines. The timing of screening was noted (before or after referral), as well as the screening method (serology or biopsy). Data were analysed to compare CD screening practices across subspecialty clinics. RESULTS: 616 consecutive patients (49±0.6 years, range 16-87 years, 58.5% females, 94% Caucasian) fulfilled inclusion criteria. CD testing was indicated in 336 (54.5%), but performed in only 145 (43.2%). The need for CD screening was highest in luminal GI and inflammatory bowel disease clinics, followed by biliary and hepatology clinics (p<0.0001); CD screening rate was highest in the luminal GI clinic (p=0.002). Of 145 patients screened, 4 patients (2.4%) had serology consistent with CD, of which 2 were proven by duodenal biopsy. Using this proportion, an additional 5 patients might have been diagnosed in 191 untested patients with indications for CD screening. CONCLUSIONS: More than 50% of patients in a tertiary GI clinic have indications for CD screening, but <50% of indicated cases are screened. Case-finding techniques therefore are suboptimal, constituting a gap in patient care and an important target for future quality improvement initiatives.

Implementation of routine screening for Lynch syndrome in university and safety-net health system settings: successes and challenges.

PURPOSE: Routine screening for evidence of DNA mismatch repair abnormalities can identify colorectal cancer patients with Lynch syndrome, but impact in usual care settings requires study. After implementing routine screening at our university and safety-net health systems as usual practice, our aims were to determine outcomes, including screening process quality. METHODS: We conducted a retrospective cohort study from 1 May 2010 to 1 May 2011. Screening included reflexive immunohistochemistry to evaluate DNA mismatch repair protein expression for patients with colorectal cancer aged ≤70 years, with a cancer genetics team following up results. Screening outcomes, as well as challenges to a high-quality screening process were evaluated. RESULTS: We included 129 patients (mean age 56 years, 36% female); 100 had immunohistochemistry screening completed. Twelve patients had abnormal immunohistochemistry: four with definite Lynch syndrome, four with probable Lynch syndrome, and three without Lynch syndrome; one patient had an incomplete work-up. Lynch syndrome was confirmed for 6/13 asymptomatic relatives tested. Screening process quality was optimal for 77.5% of patients. Barriers to optimal quality screening included ensuring reflexive immunohistochemistry completion, complete follow-up of abnormal immunohistochemistry, and timely incorporation of results into clinical decision making. CONCLUSION: Usual care implementation of routine screening for Lynch syndrome can result in significant rates of detection, even in a largely safety-net setting. To optimize implementation, challenges to high-quality Lynch syndrome screening, such as ensuring reflexive screening completion and clinically indicated genetic testing and follow-up for abnormal screens, must be identified and addressed.

Salud mental y riesgo de violencia en mujeres y adultos mayores víctimas de violencia / Mental health and risk of recidivism of violence in women and elderly victims of violence

Objetivo: Determinar la relación entre el riesgo (de continuidad o agravamiento) de violencia y la salud mental de mujeres y adultos mayores víctimas de violencia de pareja o familiar, respectivamente, cuyos casos fueron denunciados en una comisaría de Arequipa, Perú.Método: Estudio descriptivo, correlacional y transversal. La muestra fue de 428 personas. El riesgo (de continuidad o agravamiento) de violencia fue medido con “Fichas de Valoración de Riesgo” específicas para la población de estudio, validadas y utilizadas en el Perú académica y legalmente. La salud mental se evaluó mediante el Cuestionario de Síntomas (Self-Reporting-Questionnaire SRQ). Para el análisis se empleó el SPSS-IBM 24, utilizando tablas de frecuencia y contingencia, siendo la prueba estadística chi-cuadrado.Resultados: Se encontró asociación entre las características sociodemográficas y la salud mental con el nivel de riesgo de violencia, siendo el sexo, edad, grado de instrucción, lugar de nacimiento, estado civil, ingreso económico, ocupación y carga familiar, estadísticamente significativos. No se encontró una asociación significativa entre la valoración de riesgo de violencia y la presencia de al menos un trastorno psiquiátrico.Conclusión: Se concluye que en mujeres víctimas de violencia de pareja y adultos mayores víctimas de violencia familiar, el nivel de riesgo de continuidad o agravamiento de la violencia era mayor en personas de sexo femenino, de menor edad, con menor independencia y capacidad económica, con menor grado de instrucción o cuyo estado civil era de conviviente. La salud mental no sería diferente según los diferentes niveles de riesgo de violencia, a pesar que el 50% tenía posibles trastornos psiquiátricos predominando la ansiedad/depresión y trastornos psicóticos. (AU)

Objective: To determine the relationship between the risk (of continuity or aggravation) of violence and the mental health of women and older adult victims of intimate partner or family violence, respectively, whose cases were reported in a police station in Arequipa, Peru. Methods: Descriptive, correlational and cross-sectional study. The sample consisted of 428 people. The risk (of continuity or aggravation) of violence was measured with specific "Risk Assessment Forms" for the study population, validated and used in Peru academically and legally. Mental health was assessed using the Self-Reporting Questionnaire SRQ. SPSS-IBM 24 was used for the analysis, using frequency and contingency tables, with the chi-square statistical test. Results: An association was found between sociodemographic characteristics and mental health with the level of risk of violence, with sex, age, educational level, place of birth, marital status, economic income, occupation and family burden being statistically significant. No significant association was found between the assessment of risk of violence and the presence of at least one psychiatric disorder. Conclusion: It is concluded that in female victims of intimate partner violence and older adult victims of family violence, the level of risk of continuity or aggravation of violence was higher in females, younger, with less independence and economic capacity, with less education or whose marital status was that of cohabitant. Mental health was not different according to the different levels of risk of violence, although 50% had possible psychiatric disorders, predominantly anxiety/depression and psychotic disorders. (AU)

Chemoprevention of colorectal cancer in individuals with previous colorectal neoplasia: systematic review and network meta-analysis.

OBJECTIVE:  To assess the comparative efficacy and safety of candidate agents (low and high dose aspirin, non-aspirin non-steroidal anti-inflammatory drugs (NSAIDs), calcium, vitamin D, folic acid, alone or in combination) for prevention of advanced metachronous neoplasia (that is, occurring at different times after resection of initial neoplasia) in individuals with previous colorectal neoplasia, through a systematic review and network meta-analysis. DATA SOURCES:  Medline, Embase, Web of Science, from inception to 15 October 2015; clinical trial registries. STUDY SELECTION:  Randomized controlled trials in adults with previous colorectal neoplasia, treated with candidate chemoprevention agents, and compared with placebo or another candidate agent. Primary efficacy outcome was risk of advanced metachronous neoplasia; safety outcome was serious adverse events. DATA EXTRACTION:  Two investigators identified studies and abstracted data. A Bayesian network meta-analysis was performed and relative ranking of agents was assessed with surface under the cumulative ranking (SUCRA) probabilities (ranging from 1, indicating that the treatment has a high likelihood to be best, to 0, indicating the treatment has a high likelihood to be worst). Quality of evidence was appraised with GRADE criteria. RESULTS:  15 randomized controlled trials (12 234 patients) comparing 10 different strategies were included. Compared with placebo, non-aspirin NSAIDs were ranked best for preventing advanced metachronous neoplasia (odds ratio 0.37, 95% credible interval 0.24 to 0.53; SUCRA=0.98; high quality evidence), followed by low-dose aspirin (0.71, 0.41 to 1.23; SUCRA=0.67; low quality evidence). Low dose aspirin, however, was ranked the safest among chemoprevention agents (0.78, 0.43 to 1.38; SUCRA=0.84), whereas non-aspirin NSAIDs (1.23, 0.95 to 1.64; SUCRA=0.26) were ranked low for safety. High dose aspirin was comparable with low dose aspirin in efficacy (1.12, 0.59 to 2.10; SUCRA=0.58) but had an inferior safety profile (SUCRA=0.51). Efficacy of agents for reducing metachronous colorectal cancer could not be estimated. CONCLUSIONS:  Among individuals with previous colorectal neoplasia, non-aspirin NSAIDs are the most effective agents for the prevention of advanced metachronous neoplasia, whereas low dose aspirin has the most favorable risk:benefit profile. REGISTRATION:  PROSPERO (CRD42015029598).