Summary
Background
There is uncertain evidence of effectiveness of 5‐aminosalicylates (5‐ASA) to induce and maintain response and remission of active Crohn's disease (CD), and weak evidence to ...support their use in post‐operative CD.
Aim
To assess the frequency and determinants of 5‐ASA use in CD patients and to evaluate the physicians' perception of clinical response and side effects to 5‐ASA.
Methods
Data from the Swiss Inflammatory Bowel Disease Cohort, which collects data since 2006 on a large sample of IBD patients, were analysed. Information from questionnaires regarding utilisation of treatments and perception of response to 5‐ASA were evaluated. Logistic regression modelling was performed to identify factors associated with 5‐ASA use.
Results
Of 1420 CD patients, 835 (59%) were ever treated with 5‐ASA from diagnosis to latest follow‐up. Disease duration >10 years and colonic location were both significantly associated with 5‐ASA use. 5‐ASA treatment was judged to be successful in 46% (378/825) of treatment episodes (physician global assessment). Side effects prompting stop of therapy were found in 12% (98/825) episodes in which 5‐ASA had been stopped.
Conclusions
5‐Aminosalicylates were frequently prescribed in patients with Crohn's disease in the Swiss IBD cohort. This observation stands in contrast to the scientific evidence demonstrating a very limited role of 5‐ASA compounds in the treatment of Crohn's disease.
Sedation and monitoring practice during colonoscopy varies between centers and over time. Knowledge of current practice is needed to ensure quality of care and help focus future research. The ...objective of this study was to examine sedation and monitoring practice in endoscopy centers internationally.
This observational study included consecutive patients referred for colonoscopy at 21 centers in 11 countries. Endoscopists reported sedation and monitoring practice, using a standard questionnaire for each patient.
6004 patients were included in this study, of whom 53 % received conscious/moderate sedation during colonoscopy, 30 % received deep sedation, and 17 % received no sedation. Sedation agents most commonly used were midazolam (47 %) and opioids (33 %). Pulse oximetry was done during colonoscopy in 77 % of patients, blood pressure monitoring in 34 %, and electrocardiography in 24 %. Pulse oximetry was most commonly used for moderately sedated patients, while blood pressure monitoring and electrocardiography were used predominantly for deeply sedated patients. Sedation and monitoring use ranged from 0 % to 100 % between centers. Oxygen desaturation (</= 85 %) occurred in 5 % of patients, of whom 80 % were moderately sedated. On average, three staff members were involved in procedures. An anesthesiologist was present during 27 % of colonoscopies, and during 85 % of colonoscopies using deep sedation.
Internationally, sedation and monitoring practice during colonoscopy varied widely. Moderate sedation was the most common sedation method used and electronic monitoring was used in three-quarters of patients. Deep sedation tended to be more resource-intensive, implying a greater use of staff and monitoring.
The quality of colon cleansing is a major determinant of quality of colonoscopy. To our knowledge, the impact of bowel preparation on the quality of colonoscopy has not been assessed prospectively in ...a large multicenter study. Therefore, this study assessed the factors that determine colon-cleansing quality and the impact of cleansing quality on the technical performance and diagnostic yield of colonoscopy.
Twenty-one centers from 11 countries participated in this prospective observational study. Colon-cleansing quality was assessed on a 5-point scale and was categorized on 3 levels. The clinical indication for colonoscopy, diagnoses, and technical parameters related to colonoscopy were recorded.
A total of 5832 patients were included in the study (48.7% men, mean age 57.6 15.9 years). Cleansing quality was lower in elderly patients and in patients in the hospital. Procedures in poorly prepared patients were longer, more difficult, and more often incomplete. The detection of polyps of any size depended on cleansing quality: odds ratio (OR) 1.73: 95% confidence interval (CI)1.28, 2.36 for intermediate-quality compared with low-quality preparation; and OR 1.46: 95% CI1.11, 1.93 for high-quality compared with low-quality preparation. For polyps >10 mm in size, corresponding ORs were 1.0 for low-quality cleansing, OR 1.83: 95% CI1.11, 3.05 for intermediate-quality cleansing, and OR 1.72: 95% CI1.11, 2.67 for high-quality cleansing. Cancers were not detected less frequently in the case of poor preparation.
Cleansing quality critically determines quality, difficulty, speed, and completeness of colonoscopy, and is lower in hospitalized patients and patients with higher levels of comorbid conditions. The proportion of patients who undergo polypectomy increases with higher cleansing quality, whereas colon cancer detection does not seem to critically depend on the quality of bowel preparation.
To summarize the published literature on assessment of appropriateness of colonoscopy for screening for colorectal cancer (CRC) in asymptomatic individuals without personal history of CRC or polyps, ...and report appropriateness criteria developed by an expert panel, the 2008 European Panel on the Appropriateness of Gastrointestinal Endoscopy, EPAGE II.
A systematic search of guidelines, systematic reviews, and primary studies regarding colonoscopy for screening for colorectal cancer was performed. The RAND/UCLA Appropriateness Method was applied to develop appropriateness criteria for colonoscopy in these circumstances.
Available evidence for CRC screening comes from small case-controlled studies, with heterogeneous results, and from indirect evidence from randomized controlled trials (RCTs) on fecal occult blood test (FOBT) screening and studies on flexible sigmoidoscopy screening. Most guidelines recommend screening colonoscopy every 10 years starting at age 50 in average-risk individuals. In individuals with a higher risk of CRC due to family history, there is a consensus that it is appropriate to offer screening colonoscopy at < 50 years. EPAGE II considered screening colonoscopy appropriate above 50 years in average-risk individuals. Panelists deemed screening colonoscopy appropriate for younger patients, with shorter surveillance intervals, where family or personal risk of colorectal cancer is higher. A positive FOBT or the discovery of adenomas at sigmoidoscopy are considered appropriate indications.
Despite the lack of evidence based on randomized controlled trials (RCTs), colonoscopy is recommended by most published guidelines and EPAGE II criteria available online (http://www.epage.ch), as a screening option for CRC in individuals at average risk of CRC, and undisputedly as the main screening tool for CRC in individuals at moderate and high risk of CRC.
Liver steatosis is a frequent finding in chronic hepatitis C. An association has been suggested between steatosis and fibrosis progression rate, but the pathogenetic mechanisms linking fatty ...infiltration and collagen deposition are unknown.
We measured the levels of insulin resistance (as HOMA score) and leptin in 221 non-diabetic chronic hepatitis C patients, to assess their impact on liver steatosis and fibrosis, relative to other factors, using a multivariable logistic regression.
When all 221 patients were considered, steatosis was associated with excessive alcohol intake, genotype 3, and serum HCV RNA level, whereas fibrosis was associated with HOMA score and age. In 152 patients infected with genotype non-3, steatosis was associated with alcohol abuse and HCV RNA level, and fibrosis with HOMA score and age. In the 69 patients with genotype 3, steatosis and fibrosis were associated with each other. The association between fibrosis and HOMA score held also when 22 obese patients were excluded from the analysis. Levels of insulin resistance were not correlated with the presence of steatosis.
Thus, insulin resistance (but not leptin) may play a role in fibrogenesis in chronic hepatitis C patients infected with genotype non-3.
Appropriate use of colonoscopy is a key component of quality management in gastrointestinal endoscopy. In an update of a 1998 publication, the 2008 European Panel on the Appropriateness of ...Gastrointestinal Endoscopy (EPAGE II) defined appropriateness criteria for various colonoscopy indications. This introductory paper therefore deals with methodology, general appropriateness, and a review of colonoscopy complications.
The RAND/UCLA Appropriateness Method was used to evaluate the appropriateness of various diagnostic colonoscopy indications, with 14 multidisciplinary experts using a scale from 1 (extremely inappropriate) to 9 (extremely appropriate). Evidence reported in a comprehensive updated literature review was used for these decisions. Consolidation of the ratings into three appropriateness categories (appropriate, uncertain, inappropriate) was based on the median and the heterogeneity of the votes. The experts then met to discuss areas of disagreement in the light of existing evidence, followed by a second rating round, with a subsequent third voting round on necessity criteria, using much more stringent criteria (i. e. colonoscopy is deemed mandatory).
Overall, 463 indications were rated, with 55 %, 16 % and 29 % of them being judged appropriate, uncertain and inappropriate, respectively. Perforation and hemorrhage rates, as reported in 39 studies, were in general < 0.1 % and < 0.3 %, respectively
The updated EPAGE II criteria constitute an aid to clinical decision-making but should in no way replace individual judgment. Detailed panel results are freely available on the internet (www.epage.ch) and will thus constitute a reference source of information for clinicians.
Neoplastic lesions in the digestive-tract mucosa are termed "superficial" when the depth of invasion is limited to the mucosa and submucosa. The endoscopic appearance has a predictive value for ...invasion into the submucosa, which is critical for the risk of nodal metastases.
The endoscopic morphology of superficial lesions can be assessed with a standard video endoscope after spraying of a dye--an iodine-potassium iodide solution for the stratified squamous epithelium, or an indigo carmine solution for the columnar epithelium. In 2002, a workshop was held in Paris to explore the relevance of the Japanese classification. The conclusions were revised in 2003 in Osaka in relation to the definition of the subtypes used in endoscopy and the evaluation of the depth of invasion into the submucosa. In Japan, the description of advanced cancer in the digestive-tract mucosa using types 1 - 4 is supplemented by a type 0 when the endoscopic appearance is that of a superficial lesion. Type 0 is divided into three categories: protruding (0 - I), nonprotruding and nonexcavated (0 - II), and excavated (0 - III). Type 0 - II lesions are then subdivided into slightly elevated (IIa), flat (IIb), or depressed (IIc). Nonprotruding depressed lesions are associated with a higher risk of submucosal invasion. After endoscopic resection, invasion into the submucosa is an important criterion for the necessity of additional surgical resection. Micrometer analysis of the depth of invasion in the specimen is more precise, and distinct cut-off limits have been established in the esophagus, stomach, and large bowel.
The morphology of superficial and nonprotruding neoplastic lesions is relevant to the prognosis. Following endoscopic detection, the lesions are analyzed using chromoendoscopy and assigned a subtype of the type 0 classification. The choice between endoscopic or surgical treatment is based on this description.
AbstractObjective To examine the appropriateness and necessity of colonoscopy across Europe. Design Prospective observational study. Setting A total of 21 gastrointestinal centers from 11 countries. ...Participants Consecutive patients referred for colonoscopy at each center. Intervention Appropriateness criteria developed by the European Panel on the Appropriateness of Gastrointestinal Endoscopy, using the RAND appropriateness method, were used to assess the appropriateness of colonoscopy. Main outcome measure Appropriateness of colonoscopy. Results A total of 5213 of 6004 (86.8%) patients who underwent diagnostic colonoscopy and had an appropriateness rating were included in this study. According to the criteria, 20, 26, 27, or 27% of colonoscopies were judged to be necessary, appropriate, uncertain, or inappropriate, respectively. Older patients and those with a major illness were more likely to have an appropriate or necessary indication for colonoscopy as compared to healthy patients or patients who were 45–54 years old. As compared to screening patients, patients who underwent colonoscopy for iron-deficiency anemia OR: 30.84, 95% CI: 19.79–48.06 or change in bowel habits OR: 3.69, 95% CI: 2.74–4.96 were more likely to have an appropriate or necessary indication, whereas patients who underwent colonoscopy for abdominal pain OR: 0.64, 95% CI: 0.49–0.83 or chronic diarrhea OR: 0.54, 95% CI: 0.40–0.75 were less likely to have an appropriate or necessary indication. Conclusions This study identified significant proportions of inappropriate colonoscopies. Prospective use of the criteria by physicians referring for or performing colonoscopies may improve appropriateness and quality of care, especially in younger patients and in patients with nonspecific symptoms.
The adductor canal block provides pain relief on the anterior aspect of the knee after arthroplasty. Pain on the posterior aspect may be treated either by partial local infiltration analgesia of the ...posterior capsule or by a tibial nerve block. This randomized, controlled, triple-blinded trial tests the hypothesis that a tibial nerve block would provide superior analgesia compared to posterior capsule infiltration in patients scheduled for total knee arthroplasty under spinal anesthesia with an adductor canal block.
Sixty patients were randomized to receive either infiltration of the posterior capsule by the surgeon with ropivacaine 0.2%, 25 mL, or a tibial nerve block with 10 mL of ropivacaine 0.5%. Sham injections were performed to guarantee proper blinding. The primary outcome was intravenous morphine consumption at 24 h. Secondary outcomes included intravenous morphine consumption, pain scores at rest and on movement, and different functional outcomes, measured at up to 48 h. When necessary, longitudinal analyses were performed with a mixed-effects linear model.
The median (interquartile range) of cumulative intravenous morphine consumption at 24 h was 12 mg (4–16) and 8 mg (2–14) in patients having the infiltration or the tibial nerve block respectively (p = 0.20). Our longitudinal model showed a significant interaction between group and time in favor of the tibial nerve block (p = 0.015). No significant differences were present between groups in the other above-mentioned secondary outcomes.
A tibial nerve block does not provide superior analgesia when compared to infiltration. However, a tibial nerve block might be associated with a slower increase in morphine consumption over time.
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