Colonoscopy utilization and outcomes 2000 to 2011 Lieberman, David A., MD; Williams, J. Lucas, MPH; Holub, Jennifer L., MPH ...
Gastrointestinal endoscopy,
07/2014, Letnik:
80, Številka:
1
Journal Article
Recenzirano
Background Understanding colonoscopy utilization and outcomes can help determine when the procedure is most effective. Objective To study trends in utilization and outcomes of colonoscopy in the ...United States from 2000 to 2011. Design Prospective collection of colonoscopy data. Setting A total of 84 adult diverse GI practices. Patients All adult patients receiving colonoscopy for any reason. Intervention Colonoscopy. Main Outcome Measurements Polyps >9 mm or suspected malignant tumor. Results We analyzed 1,372,838 reports. The most common reason for colonoscopy in patients aged <50 years is evaluation of symptoms such as irritable bowel syndrome (IBS) (28.7%) and bleeding or anemia (35.3%). In patients aged 50 to 74 years, colorectal cancer screening accounts for 42.9% of examinations. In patients aged >74 years, surveillance for cancer or polyps is the most common indication. The use of colonoscopy for average-risk screening increased nearly 3-fold during the study period. The prevalence of large polyps increases with age and is higher in men for every procedure indication. The prevalence of large polyps in patients with symptoms of IBS was lower than in those undergoing average-risk screening (odds ratio OR 0.85; 95% confidence interval CI, 0.83-0.87). With increasing age, there was a shift from distal to proximal large polyps. The rate of proximal large polyps is higher in the black population compared with the white population (OR 1.19; 95% CI, 1.13-1.25). Limitations In the absence of pathology data, use of surrogate as the main outcome. Conclusion Colonoscopy utilization changed from 2000 to 2011, with an increase in primary screening. The proximal location of large polyps in the black population and with advancing age has implications for screening and surveillance.
Addiction consult services (ACS) engage hospitalized patients with opioid use disorder (OUD) in care and help meet their goals for substance use treatment. Little is known about how ACS affect ...mortality for patients with OUD. The objective of this study was to design and validate a model that estimates the impact of ACS care on 12-month mortality among hospitalized patients with OUD.
We developed a Markov model of referral to an ACS, post-discharge engagement in SUD care, and 12-month drug-related and non-drug related mortality among hospitalized patients with OUD. We populated our model using Oregon Medicaid data and validated it using international modeling standards.
There were 6,654 patients with OUD hospitalized from April 2015 through December 2017. There were 114 (1.7%) drug-related deaths and 408 (6.1%) non-drug related deaths at 12 months. Bayesian logistic regression models estimated four percent (4%, 95% CI = 2%, 6%) of patients were referred to an ACS. Of those, 47% (95% CI = 37%, 57%) engaged in post-discharge OUD care, versus 20% not referred to an ACS (95% CI = 16%, 24%). The risk of drug-related death at 12 months among patients in post-discharge OUD care was 3% (95% CI = 0%, 7%) versus 6% not in care (95% CI = 2%, 10%). The risk of non-drug related death was 7% (95% CI = 1%, 13%) among patients in post-discharge OUD treatment, versus 9% not in care (95% CI = 5%, 13%). We validated our model by evaluating its predictive, external, internal, face and cross validity.
Our novel Markov model reflects trajectories of care and survival for patients hospitalized with OUD. This model can be used to evaluate the impact of other clinical and policy changes to improve patient survival.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
IMPORTANCE Maternal smoking during pregnancy adversely affects offspring lung development, with lifelong decreases in pulmonary function and increased asthma risk. In a primate model, vitamin C ...blocked some of the in-utero effects of nicotine on lung development and offspring pulmonary function. OBJECTIVE To determine if newborns of pregnant smokers randomized to receive daily vitamin C would have improved results of pulmonary function tests (PFTs) and decreased wheezing compared with those randomized to placebo. DESIGN, SETTING, AND PARTICIPANTS Randomized, double-blind trial conducted in 3 sites in the Pacific Northwest between March 2007 and January 2011. One hundred fifty-nine newborns of randomized pregnant smokers (76 vitamin C treated and 83 placebo treated) and 76 newborns of pregnant nonsmokers were studied with newborn PFTs. Follow-up assessment including wheezing was assessed through age 1 year, and PFTs were performed at age 1 year. INTERVENTIONS Pregnant women were randomized to receive vitamin C (500 mg/d) (n = 89) or placebo (n = 90). MAIN OUTCOMES AND MEASURES The primary outcome was measurement of newborn pulmonary function (ratio of the time to peak tidal expiratory flow to expiratory time TPTEF:TE and passive respiratory compliance per kilogram Crs/kg) within 72 hours of age. Secondary outcomes included incidence of wheezing through age 1 year and PFT results at age 1 year. A subgroup of pregnant smokers and nonsmokers had genotyping performed. RESULTS Newborns of women randomized to vitamin C (n = 76), compared with those randomized to placebo (n = 83), had improved pulmonary function as measured by TPTEF:TE (0.383 vs 0.345 adjusted 95% CI for difference, 0.011-0.062; P = .006) and Crs/kg (1.32 vs 1.20 mL/cm H2O/kg 95% CI, 0.02-0.20; P = .01). Offspring of women randomized to vitamin C had significantly decreased wheezing through age 1 year (15/70 21% vs 31/77 40%; relative risk, 0.56 95% CI, 0.33-0.95; P = .03). There were no significant differences in the 1-year PFT results between the vitamin C and placebo groups. The effect of maternal smoking on newborn lung function was associated with maternal genotype for the α5 nicotinic receptor (rs16969968) (P < .001 for interaction). CONCLUSIONS AND RELEVANCE Supplemental vitamin C taken by pregnant smokers improved newborn PFT results and decreased wheezing through 1 year in the offspring. Vitamin C in pregnant smokers may be an inexpensive and simple approach to decrease the effects of smoking in pregnancy on newborn pulmonary function and respiratory morbidities. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00632476
Background & Aims Colorectal cancer risk differs based on patient demographics. We aimed to measure the prevalence of significant colorectal polyps in average-risk individuals and to determine ...differences based on age, sex, race, or ethnicity. Methods In a prospective study, colonoscopy data were collected, using an endoscopic report generator, from 327,785 average-risk adults who underwent colorectal cancer screening at 84 gastrointestinal practice sites from 2000 to 2011. Demographic characteristics included age, sex, race, and ethnicity. The primary outcome was the presence of suspected malignancy or large polyp(s) >9 mm. The benchmark risk for age to initiate screening was based on white men, 50−54 years old. Results Risk of large polyps and tumors increased progressively in men and women with age. Women had lower risks than men in every age group, regardless of race. Blacks had higher risk than whites from ages 50 through 65 years and Hispanics had lower risk than whites from ages 50 through 80 years. The prevalence of large polyps was 6.2% in white men 50−54 years old. The risk was similar among the groups of white women 65−69 years old, black women 55−59 years old, black men 50−54 years old, Hispanic women 70−74 years old, and Hispanic men 55−59 years old. The risk of proximal large polyps increased with age, female sex, and black race. Conclusions There are differences in the prevalence and location of large polyps and tumors in average-risk individuals based on age, sex, race, and ethnicity. These findings could be used to select ages at which specific groups should begin colorectal cancer screening.
Lipoic acid (alpha lipoic acid, thioctic acid) is a popular over-the-counter antioxidant and insulin-mimetic supplement under investigation in a variety of conditions including multiple sclerosis, ...diabetes, and schizophrenia. Unfortunately, high-grade proteinuria was an unexpected adverse event specific to the treatment arm of our clinical trial investigating lipoic acid supplementation in patients with multiple sclerosis. This observation led to detection of similar patients in our nephrology practice. Here, we describe four biopsy-proven cases of neural epidermal growth factor-like 1 (NELL1)–associated membranous nephropathy following lipoic acid supplementation and a fifth suspected case. Discontinuation of lipoic acid and supportive therapy resulted in remission.
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IMPORTANCE: Vitamin C supplementation (500 mg/d) for pregnant smokers has been reported to increase offspring airway function as measured by forced expiratory flow (FEF) through age 12 months; ...however, its effects on airway function at age 5 years remain to be assessed. OBJECTIVE: To assess whether vitamin C supplementation in pregnant smokers is associated with increased and/or improved airway function in their offspring at age 5 years and whether vitamin C decreases the occurrence of wheeze. DESIGN, SETTING, AND PARTICIPANTS: This study followed up the Vitamin C to Decrease the Effects of Smoking in Pregnancy on Infant Lung Function (VCSIP) double-blind, placebo-controlled randomized clinical trial conducted at 3 centers in the US (in Oregon, Washington, and Indiana) between 2012 and 2016. Investigators and participants remain unaware of the treatment assignments. Forced expiratory flow measurements at age 5 years were completed from 2018 to 2021. INTERVENTIONS: Pregnant smokers were randomized to vitamin C (500 mg/d) or placebo treatment. MAIN OUTCOMES AND MEASURES: The primary outcome was the prespecified measurement of FEF between 25% and 75% expired volume (FEF25-75) by spirometry at age 5 years. Secondary outcomes included FEF measurements at 50% and 75% of expiration (FEF50 and FEF75), forced expiratory volume in 1 second (FEV1), and occurrence of wheeze. RESULTS: Of the 251 pregnant smokers included in this study, 125 (49.8%) were randomized to vitamin C and 126 (50.2%) were randomized to placebo. Of 213 children from the VCSIP trial who were reconsented into this follow-up study, 192 (90.1%) had successful FEF measurements at age 5 years; 212 (99.5%) were included in the analysis of wheeze. Analysis of covariance demonstrated that offspring of pregnant smokers allocated to vitamin C compared with placebo had 17.2% significantly higher mean (SE) measurements of FEF25-75 at age 5 years (1.45 0.04 vs 1.24 0.04 L/s; adjusted mean difference, 0.21 95% CI, 0.13-0.30; P < .001). Mean (SE) measurements were also significantly increased by 14.1% for FEF50 (1.59 0.04 vs 1.39 0.04 L/s; adjusted mean difference, 0.20 95% CI, 0.11-0.30; P < .001), 25.9% for FEF75 (0.79 0.02 vs 0.63 0.02 L/s; 0.16 95% CI, 0.11-0.22; P < .001), and 4.4% for FEV1 (1.13 0.02 vs 1.09 0.02 L; 0.05 95% CI, 0.01-0.09; P = .02). In addition, offspring of pregnant smokers randomized to vitamin C had significantly decreased wheeze (28.3% vs 47.2%; estimated odds ratio, 0.41 95% CI, 0.23-0.74; P = .003). CONCLUSIONS AND RELEVANCE: In this follow-up study of offspring of pregnant smokers randomized to vitamin C vs placebo, vitamin C supplementation during pregnancy resulted in significantly increased airway function of offspring at age 5 years and significantly decreased the occurrence of wheeze. These findings suggest that vitamin C supplementation for pregnant smokers may decrease the effects of smoking in pregnancy on childhood airway function and respiratory health. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03203603
Patients with substance use disorders are seven times more likely hospitalized than the general population. However, causes of death for recently hospitalized patients with Opioid Use Disorder (OUD) ...are not well described. This study describes causes of death in the year post-discharge among hospitalized patients with OUD.
We analyzed data from participants who were at least 18 years old, with Medicaid insurance, and had a diagnosis of OUD during a general hospital admission in Oregon between April 2015 and December 2017.
During the study window, 6,654 Oregon Medicaid patients with an OUD diagnosis were hospitalized. Patients were predominately female (56.7%) and White (72.2%), an average age of 44.2 years (SD = 15.4 years) and average hospital length of stay of 6.5 days (SD = 10.9 days). In the 12 months post-discharge, 522 patients died (7.8%); 301 patients from a drug or substance related cause (4.5%), including 71 from drug overdose (1.1%). Stated another way, of those who died within 12 months, 58% of deaths were attributed to drug-related causes, including 13.6% of deaths attributed to overdose; 42% died of non-drug related causes. Drug-related death was the most frequent cause of mortality.
Hospitalized patients with OUD are at high risk of death, from drug and non-drug related causes, in the year after discharge. Future research should consider not only overdose, but a more comprehensive definition of drug-related death in understanding post-discharge mortality among hospitalized patients with OUD, and care systems should work to mitigate the risk of death in this population.
This secondary analysis of a randomized clinical trial analyzes the association of vitamin C supplementation in women who smoked during pregnancy with airway function trajectory in their offspring at ...4 to 6 years of age.
Infants whose mothers smoked during pregnancy demonstrate lifelong decreases in pulmonary function. DNA methylation changes associated with maternal smoking during pregnancy have been described in ...placenta and cord blood at delivery, in fetal lung, and in buccal epithelium and blood during childhood. We demonstrated in a randomized clinical trial ( ClinicalTrials.gov identifier, NCT00632476) that vitamin C supplementation to pregnant smokers can lessen the impact of maternal smoking on offspring pulmonary function and decrease the incidence of wheeze at 1 year of age.
To determine whether vitamin C supplementation reduces changes in offspring methylation in response to maternal smoking and whether methylation at specific CpGs is also associated with respiratory outcomes.
Targeted bisulfite sequencing was performed with a subset of placentas, cord blood samples, and buccal samples collected during the NCT00632476 trial followed by independent validation of selected cord blood differentially methylated regions, using bisulfite amplicon sequencing.
The majority (69.03%) of CpGs with at least 10% methylation difference between placebo and nonsmoker groups were restored (by at least 50%) toward nonsmoker levels with vitamin C treatment. A significant proportion of restored CpGs were associated with phenotypic outcome with greater enrichment among hypomethylated CpGs.
We identified a pattern of normalization in DNA methylation by vitamin C supplementation across multiple loci. The consistency of this pattern across tissues and time suggests a systemic and persistent effect on offspring DNA methylation. Further work is necessary to determine how genome-wide changes in DNA methylation may mediate or reflect persistent effects of maternal smoking on lung function.
CONTEXT Compared with white individuals, black men and women have a higher incidence and mortality from colorectal cancer and may develop cancer at a younger age. Colorectal cancer screening might be ...less effective in black individuals, if there are racial differences in the age-adjusted prevalence and location of cancer precursor lesions. OBJECTIVES To determine and compare the prevalence rates and location of polyps sized more than 9 mm in diameter in asymptomatic black and white individuals who received colonoscopy screening. DESIGN, SETTING, AND PATIENTS Colonoscopy data were prospectively collected from 67 adult gastrointestinal practice sites in the United States using a computerized endoscopic report generator between January 1, 2004, and December 31, 2005. Data were transmitted to a central data repository, where all asymptomatic white (n = 80 061) and black (n = 5464) patients who had received screening colonoscopy were identified. MAIN OUTCOME MEASURES Prevalence and location of polyps sized more than 9 mm, adjusted for age, sex, and family history of colorectal cancer in a multivariate analysis. RESULTS Both black men and women had a higher prevalence of polyps sized more than 9 mm in diameter compared with white men and women (4227.7% vs 4964 6.2%; P < .001). Compared with white patients, the adjusted odds ratio (OR) for black men was 1.16 (95% confidence interval CI, 1.01-1.34) and the adjusted OR for black women was 1.62 (95% CI, 1.39-1.89). Black and white patients had a similar risk of proximal polyps sized more than 9 mm (OR, 1.13;95% CI, 0.93-1.38). However, in a subanalysis of patients older than 60 years, proximal polyps sized more than 9 mm were more likely prevalent in black men (P = .03) and women (P < .001) compared with white men and women. CONCLUSION Compared with white individuals, black men and women undergoing screening colonoscopy have a higher risk of polyps sized more than 9 mm, and black individuals older than 60 years are more likely to have proximal polyps sized more than 9 mm.
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