A prospective, controlled assessment of factors influencing acceptance of screening colonoscopy

Long-term patient satisfaction of gastrointestinal endoscopic procedures

Background

We prospectively assessed patient satisfaction in a Greek Academic endoscopy facility.

Methods

Consecutive outpatients filled a satisfaction questionnaire right after their endoscopy (D1), 3 days (D3) and 3 months (M3) later. Overall patient satisfaction was measured by their willingness to repeat endoscopy in our facility and to further recommend it. Participant satisfaction regarding pre-procedural, procedural and post-procedural issues was measured using a five-step Likert scale in 19 items with 4 and 5 scores indicating favorable responses. Pareto analysis was used to determine service issues requiring improvement. Late adverse events were recorded at D3 and M3 assessments.

Results

Over six months, 501 patients participated (89.4% and 87.8% response rate at D3 and M3 assessments, respectively). More than 97% of the participants would repeat the procedure in our facility and would recommend our endoscopy service, at all three assessments. Pareto analysis identified waiting time until the appointment and on the day of the examination, discomfort during and after the endoscopy, time to obtain the pathology report and overall management of the patient problems as the issues requiring improvement. No predictor of high satisfaction score has been identified. No serious late adverse events were reported.

Conclusion

Despite the overall high levels of patient satisfaction, management of patient discomfort and organizational issues need improvement.

Split-dose sodium picosulfate-magnesium citrate colonoscopy preparation achieves lower residual gastric volume with higher cleansing effectiveness than a previous-day regimen

BACKGROUND AND AIMS

It is known that sodium picosulfate-magnesium citrate (SPMC) bowel preparations are effective, well tolerated and safe, and that split-dosing is more effective for colon cleansing than previous-day regimens. Anesthetic guidelines consider that residual gastric fluid is independent of clear liquid fasting times. However, reluctance to use split-dosing persists. This may be due to limited data on residual gastric fluid volumes (RGFVs) and split-dosing bowel preparations, and that these may not be perceived as standard clear liquids. Furthermore, no studies are available on RGFV/residual gastric fluid pH (RGFpH) and SPMC. We aimed to evaluate the cleansing effectiveness and the RGFV/RGFpH achieved after an SPMC split-dosing regimen compared with a SPMC previous-day regimen.

METHODS

This was a single-center observational study. A total of 328 outpatients scheduled for simultaneous EGD and colonoscopy and following a split-dosing or previous-day regimen of SPMC were included. We prospectively measured colon cleanliness by using the Ottawa Bowel Preparation Scale, RGFV, and RGFpH.

RESULTS

Ottawa Bowel Preparation Scale scores for overall, right, mid-colon, and colon fluid were significantly better in the split-dosing group. In the split-dosing group, the 3- to 4-hour fasting time consistently achieved the best cleansing quality. RGFV was significantly lower in the split-dosing group (11.09 vs 18.62, P < .001). No significant differences in RGFpH were detected.

CONCLUSIONS

Split-dosing SPMC provides higher colon cleansing quality with lower RGFVs than previous-day SPMC regimens. SPMC in split-dosing acts exactly as a standard clear liquid acts, and thus anesthetic guidelines on this issue may be applied with no concerns.

How to improve colon cancer screening rates

Colorectal carcinoma is a common cause of death throughout the world and may be prevented by routine control, which can detect precancerous neoplasms and early cancers before they undergo malignant transformation or metastasis. Three strategies may improve colon cancer screening rates: convince the population about the importance of undergoing a screening test; achieve higher efficacy in standard screening tests and make them more available to the community and develop new more sensitive and efficacious screening methods and make them available as routine tests. In this light, the present study seeks to review these three means through which to increase colon cancer screening rates.

A Randomized Controlled Trial Evaluating a Low-Volume PEG Solution Plus Ascorbic Acid versus Standard PEG Solution in Bowel Preparation for Colonoscopy

Evaluation of polyethylene glycol electrolyte lavage solution containing ascorbic acid (PEG-ASC) has been controversial in the point of its hyperosmolarity, especially in old population. So we therefore designed the present study to compare the efficacy, acceptability, tolerability, and safety of 1.5 L PEG+ASC and 2 L standard PEG electrolyte solution (PEG-ELS), not only in the general population, but also in patients of advanced age. Randomization was stratified by age (<70 years or 70> years), and hematological and biochemical parameters were compared in each age group, especially with respect to the safety profile of each regimen. As a result, the 1.5-L PEG-ASC regimen had higher patient acceptability than the 2-L PEG-ELS regimen. Tolerability, bowel cleansing, and safety were similar between regimens. However, we demonstrated significant statistical changes in the hematological and biochemical parameters after taking bowel preparation solutions, not only in the PEG+ASC group, but also in the PEG-ELS group. No significant differences in the safety profile were found between subjects aged less than 70 years and those aged 70 years or more; nevertheless, regardless of age, proper hydration is needed throughout the bowel preparation process.

Automated volumetric analysis for comparison of oral sulfate solution (SUPREP) with established cathartic agents at CT colonography

PURPOSE

To objectively compare residual colonic fluid volume and attenuation of oral sulfate solution (OSS) with four different established cathartic regimens using an automated volumetric software tool at CT colonography (CTC).

METHODS

This HIPAA-compliant study had institutional review board approval. Volumetric analysis of residual contrast-tagged colonic fluid was performed on CTC studies in 263 adults (mean age 60.1 years; 137M/126F) using an automated volumetric software tool. Twenty-three patients receiving 177 mL OSS (SUPREP; single-bottle purgation) were compared with 60 patients each receiving 45 mL sodium phosphate (NaP), 90 mL NaP (2× NaP), 592 mL (two bottles) magnesium citrate (MgC), and 4,000 mL polyethylene glycol (PEG). All patients received oral contrast cleansing after catharsis. Data were analyzed with unpaired t test with Welch correction and F test.

RESULTS

The mean volume of residual colonic fluid was less with OSS (125 ± 60 mL) than for established cathartic agents: 2× NaP (206 ± 125 mL, P < 0.0001), MgC (184 ± 125 mL, P < 0.01), PEG (166 ± 114 mL, P < 0.05), and NaP (165 ± 135 mL, P = 0.067). Variance of volumes was also significantly lower for OSS (range 28-251 mL) than for established agents (range 4-853 mL) (all P < 0.01). Mean fluid attenuation was higher with OSS (956 ± 168 HU) than for established agents (all P < 0.05): 2× NaP (455 ± 191 HU), MgC (691 ± 154 HU), NaP (779 ± 127 HU), and PEG (843 ± 193 HU).

CONCLUSIONS

Automated volumetry allows rapid objective assessment of bowel preparation quality at CTC. Purgation with the novel oral sulfate solution (SUPREP) consistently resulted in less residual colonic fluid and higher fluid attenuation compared with established cathartic regimens.

The burden of bowel preparations in patients undergoing elective colonoscopy

BACKGROUND

An adequate bowel preparation is an important quality measure for optimal colonoscopy.

AIMS

The aim of this article is to study the burden of bowel preparations by examining seven specific variables (hunger, taste, volume, sleep, social, work, and adverse events (AEs)).

METHODS

Ambulatory patients undergoing elective colonoscopy completed a questionnaire regarding their experience with the prescribed preparation. The seven study variables were graded using a numerical scale of 0-10 (best to worst). A score >6 was considered to indicate a significant impact and used as primary outcome. Patients were also asked to grade in descending order what they perceived as the worst aspect of the preparation.

RESULTS

A total of 216 patients completed the survey. Preparations consisted of split-dose sodium picosulfate (SPS) (n = 49), split-dose 4 l PEG ± menthol (n = 49), full-dose PEG (n = 68), and 2 l split-dose PEG + ascorbic acid (n = 50). Except for work and AEs, all variables were considered to have a negative impact by >20% of patients (range 20.4-34.2). SPS was superior to PEG regimens in taste (4.1% vs. 35.9%) and volume (0% vs. 44.9%) (p < 0.05 for both) but inferior for hunger (30.6% vs. 19.2%; p = 0.09). The addition of menthol to PEG significantly improved taste (22.4% vs. 41.5%; p = 0.02). Sleep disturbances were most common with SPS and least with split-dose PEG (30.6% vs. 17.4%; p < 0.05). Overall, patients ranked volume, taste, and hunger as most burdensome.

CONCLUSIONS

The burden of bowel preparation is substantial. An informed personalized choice of preparation may improve adherence, tolerability and colon cleansing.

Is the anesthesiologist necessary in the endoscopy suite? A review of patients, payers and safety

The use of propofol for sedation during endoscopy has been increasing, particularly given its association with superior patient satisfaction. Propofol sedation may also allow for higher quality endoscopy exams, increased efficiency of endoscopy suites and most particularly, permit better patient compliance with colonoscopy for colorectal cancer screening. However, propofol is typically provided by anesthesia specialists via monitored anesthesia care, and is associated with significant economic burden. Given the increasing use of monitored anesthesia care, which adds significant costs to endoscopy, payers are likely to react with changes in payer policies. One alternative to monitored anesthesia care is non-anesthesiologist administered propofol, which due to safety concerns and a lack of reimbursement has not been widely adopted in the US.

Gene Expression Signatures Based on Variability can Robustly Predict Tumor Progression and Prognosis

Gene expression signatures are commonly used to create cancer prognosis and diagnosis methods, yet only a small number of them are successfully deployed in the clinic since many fail to replicate performance on subsequent validation. A primary reason for this lack of reproducibility is the fact that these signatures attempt to model the highly variable and unstable genomic behavior of cancer. Our group recently introduced gene expression anti-profiles as a robust methodology to derive gene expression signatures based on the observation that while gene expression measurements are highly heterogeneous across tumors of a specific cancer type relative to the normal tissue, their degree of deviation from normal tissue expression in specific genes involved in tissue differentiation is a stable tumor mark that is reproducible across experiments and cancer types. Here we show that constructing gene expression signatures based on variability and the anti-profile approach yields classifiers capable of successfully distinguishing benign growths from cancerous growths based on deviation from normal expression. We then show that this same approach generates stable and reproducible signatures that predict probability of relapse and survival based on tumor gene expression. These results suggest that using the anti-profile framework for the discovery of genomic signatures is an avenue leading to the development of reproducible signatures suitable for adoption in clinical settings.

Assessment of Jordanian Patient's Colorectal Cancer Awareness and Preferences towards CRC Screening: Are Jordanians Ready to Embrace CRC Screening?

BACKGROUND

Colorectal cancer (CRC is increasingly becoming a major cause of cancer morbidity and mortality in Jordan. However the population's level of awareness about CRC, CRC screening test preferences and willingness to embrace screening are not known. The aim of this study was to assess the level of CRC awareness and screening preferences among Jordanian patients.

MATERIALS AND METHODS

A survey assessing the CRC knowledge levels was distributed among patients attending outpatient gastroenterology clinics in public hospitals throughout Jordan. A total of 800 surveys were distributed and of these 713 (89.1%) were returned.

RESULTS

Only 22% of the participants correctly judged CRC among the choices provided as the commonest cause of cancer related deaths. The majority of participants (68.3%) underestimated their risk for CRC. Only 26.8% correctly judged their life time risk while 5% overestimated their risk. Two thirds of participants (66%) were willing to pay 500 Jordanian Dinars (equivalent to 706 US$) in order to get a prompt colonoscopy if recommended by their physician, while 25.5% reported that they would rather wait for 6 months in order to get a free colonoscopy.

CONCLUSIONS

Although the participants tended to underestimate their risk for CRC, they were mostly aware of CRC as a major cause of mortality and were willing to embrace the concept of CRC screening and bear the related financial costs. These findings about CRC awareness and propensity for screening provide a good foundation as the Jordanian health system moves forward with initiatives to promote CRC screening and prevention.

Low-residue breakfast during the preparation for colonoscopy using a polyethylene glycol electrolyte solution: a randomised non-inferiority trial

Goals

To test the hypothesis that the use of a low-residue breakfast (LRB) the day prior to colonoscopy was not inferior to consuming clear fluids alone (CFD) in patients undergoing outpatient colonoscopy with a polyethylene glycol (PEG) bowel preparation.

Background

Optimal colon cleansing is essential for complete visualisation of the mucosa during colonoscopy. Few studies have examined the effect of diet on the quality of bowel cleansing or tolerance in patients using a PEG bowel preparation for colonoscopy.

Methods

Randomised, single-blinded non-inferiority trial. Adult patients scheduled for outpatient colonoscopy with PEG solution were randomised to an LRB followed by clear fluids or CFD using either a traditional or split-dose PEG solution for bowel preparation. The primary outcome was colon cleansing based on the Ottawa Bowel Preparation Score (OBPS).

Results

On an intention-to-treat (ITT) basis, a total of 109 and 105 patients were included in the CFD and LRB arms, respectively, with 116 and 98 patients, respectively, for the per-protocol (PP) analysis. Although there was no difference in the mean total OBPS between the CFD or LRB arms in either the ITT or PP analysis, the threshold for non-inferiority was not met. Patient acceptance of the regimens was higher in the LRB arm than in the CFD arm in the ITT and PP analyses.

Conclusions

This study failed to show the non-inferiority of an LRB in patients receiving bowel preparation with a PEG-based solution. A CFD should be prescribed when using a PEG bowel preparation.

Trial registration number

This trial is registered at ClinicalTrials.gov (NCT01454388).

Feasibility study of minimal prepared hydroflush screening colonoscopy

BACKGROUND

Although screening colonoscopy is effective for early detection of colorectal cancer (CRC), screening rates remain low. Multiple factors are thought to be responsible for the low rates of screening colonoscopy, but bowel preparation appears to be a key deterrent. Tolerability issues with bowel preparations may lead to poor patient compliance, inadequate colon cleansing, and reduced detection of colonic polyps.

AIM

The aim of this article is to evaluate the feasibility, safety, and outcomes of minimally prepared intra-procedural hydroflush technique as an alternative to traditional bowel preparation in screening colonoscopy.

DESIGN

We conducted a prospective feasibility study of intraprocedural hydroflush technique aided by water-jet pumps and a mechanical suction novel device following minimal bowel preparation for CRC screening.

PATIENTS AND METHODS

Nine procedures were performed in nine healthy individuals scheduled for routine screening colonoscopy. Preparation included mild diet restriction, laxative tablets two to three days prior to the procedure and two Fleet enemas one to two hours before the colonoscopy. The cleanliness of the colon was assessed by using the Boston bowel preparation scale. Insertion and withdrawal times were recorded.

RESULTS

Complete colonoscopy to the cecum was performed in all patients (100%). Mean time to the cecum was 5.78 ± 2.68 minutes, and mean withdrawal time was 15.33 ± 3.94 minutes. Endoscopic visualization of the entire mucosa was achieved in all cases with no colonoscopy repeated because of inadequate preparation. Four polyps have been detected and removed in three patients. Mild mucosal erosions were seen in some areas where the suction was used extensively, similar to those that can be seen during conventional colonoscopy. Mild stiffness of the shaft of the scope was noted.

LIMITATIONS

This was an uncontrolled feasibility study of selected patients.

CONCLUSIONS

Minimally prepared colonoscopy with the intra-procedural hydroflush technique for colorectal screening is feasible. The water exchange technology compensates for the mild stiffness of the scope. This technique might increase patients' compliance for CRC screening.

The impact of chronic opioid use on colonoscopy outcomes

BACKGROUND

Endoscopic procedures are frequently performed on patients chronically on opioids, raising concerns about the safety and efficacy of conventional sedation.

AIMS

We hypothesized that chronic opioid use is associated with longer procedure times, higher dosages of sedation medications, and an increase in adverse effects.

METHODS

This is a retrospective review from June 2012 to June 2013. Patients on chronic opioids (opioids use ≥ 12 weeks) were compared to randomly selected patients matched for age, race, and sex. Multivariate regression analysis was performed to identify factors that were independently predictive of longer procedure times.

RESULTS

Patients on chronic opioids required higher doses of fentanyl (122.0 ± 45.3 vs. 105.8 ± 47.2 µg; P < 0.0001) and midazolam (5.3 ± 5.3 vs. 4.4 ± 2 mg; P = 0.0037) and were more likely to receive diphenhydramine (42.8 vs. 22.6 %; P < 0.001). The induction period (11.3 ± 8.8 vs. 7.5 ± 4.0 min), duration of procedure (39.1 ± 17.5 vs. 33.4 ± 14.1 min), and recovery times (38.7 ± 15.3 vs. 33.8 ± 12.1 min) were significantly longer for patients on chronic opioids. In the multivariate regression analysis, opioid use was an independent predictor of longer procedure duration (P < 0.05). Hypotensive episodes did not differ between groups (2.8 vs. 2.7 %; P = 0.8). However, patients on chronic opioids experienced more pain (13.4 vs. 5.9 %; P 0.001) and hypertensive episodes (8.1 vs. 2.8 %; P 0.002).

CONCLUSION

Patients on chronic opioids represent a high-risk population with longer procedural times and more discomfort, despite higher dosages of sedative agents. Prospective studies are required to define the risks and benefits of more costly alternative sedation strategies for patients on chronic opioids.

Racial/Ethnic Minorities Ineligible for Direct Access Colonoscopy (DAC): Identifying Patients Who Fall Through the Cracks

OBJECTIVE

Patients ineligible for direct access colonoscopy (DAC) are typically referred for a pre-colonoscopy consultation with gastroenterology (GI). However, the referral from primary care to GI creates the potential for patients to drop out of treatment. The primary objective of the current study was to examine the proportion of participants deemed ineligible for DAC that (1) attended an appointment with GI and (2) completed a screening colonoscopy. The second aim of the study was to examine predictors of screening colonoscopy adherence.

METHODS

Participants (N = 144) were average-risk patients who received a primary care referral for a screening colonoscopy and were deemed ineligible for DAC between 2008 and 2012. Following the primary care visit, participants completed a questionnaire that assessed demographics and psychological factors. Medical chart review determined whether participants completed the screening colonoscopy via the GI referral.

RESULTS

Of the 144 participants, only 19 (13 %) completed the screening colonoscopy via the GI referral. Multiple regression analyses revealed that decisional balance was the only unique predictor of screening colonoscopy adherence.

CONCLUSIONS

Patients deemed ineligible for DAC are highly unlikely to complete a screening colonoscopy. Interventions are needed to increase screening colonoscopy adherence in this vulnerable population.

Development and validation of the Mayo Clinic Bowel Prep Tolerability Questionnaire

BACKGROUND

Bowel cleansing is paramount for colonoscopy quality. Unfortunately, an adequate bowel preparation is often limited by side effects and/or patient's intolerance to bowel preparation solutions. Comparisons among different preparations are limited by the lack of validated instruments designed to assess patient's tolerability.

AIM

To develop and validate a simple, comprehensive instrument to assess bowel preparation tolerability in patients undergoing colonoscopy.

METHODS

Development and validation by phases: Phase I (bibliographic search and questionnaire design); Phase II (assessment of content validity and modification of the questionnaire); Phase III (assessment of reproducibility, final validation, and definitive version of the questionnaire).

RESULTS

The initial draft of the questionnaire was generated based on a systematic literature review and feedback from a panel of consultants. Content validity was tested in a focus group of 25 patients undergoing colonoscopy. Patients' suggestions were reviewed by the research team and a second draft of the questionnaire was generated. Final validation and reproducibility were successfully tested (agreement: 86-100%, kappa: 0.77-1.00) in a convenience sample of 100 patients undergoing bowel preparation with different cleansing solutions.

CONCLUSION

The Mayo Clinic Bowel Prep Tolerability Questionnaire is a simple, comprehensive instrument suitable to evaluate the tolerability of various types of bowel preparations.

Readability, suitability, and health content assessment of web-based patient education materials on colorectal cancer screening

BACKGROUND

Colorectal cancer (CRC) screening rates in the Unites States are still below target level. Web-based patient education materials are used by patients and providers to provide supplemental information on CRC screening. Low literacy levels and patient perceptions are significant barriers to screening. There are little data on the quality of these online materials from a health literacy standpoint or whether they address patients' perceptions.

OBJECTIVE

To evaluate the readability, suitability, and health content of web-based patient education materials on colon cancer screening.

DESIGN

Descriptive study.

SETTING

Web-based patient materials.

INTERVENTIONS

Twelve reputable and popular online patient education materials were evaluated. Readability was measured by using the Flesch-Kincaid Reading Grade Level, and suitability was determined by the Suitability Assessment of Materials, a scale that considers characteristics such as content, graphics, layout/typography, and learning stimulation. Health content was evaluated within the framework of the Health Belief Model, a behavioral model that relates patients' perceptions of susceptibility to disease, severity, and benefits and barriers to their medical decisions. Each material was scored independently by 3 reviewers.

MAIN OUTCOME MEASUREMENTS

Flesch-Kincaid Reading Grade Level score, Suitability Assessment of Materials score, health content score.

RESULTS

Readability for 10 of 12 materials surpassed the maximum recommended sixth-grade reading level. Five were 10th grade level and above. Only 1 of 12 materials received a superior suitability score; 3 materials received inadequate scores. Health content analysis revealed that only 50% of the resources discussed CRC risk in the general population and <25% specifically addressed patients at high risk, such as African Americans, smokers, patients with diabetes, and obese patients. For perceived barriers to screening, only 8.3% of resources discussed embarrassment, 25% discussed pain with colonoscopy, 25% addressed cost of colonoscopy, and none specifically mentioned the need to get colonoscopy when no symptoms are present. No material discussed the social benefits of screening.

LIMITATIONS

Descriptive design.

CONCLUSION

Most online patient education materials for CRC screening are written beyond the recommended sixth-grade reading level, with suboptimal suitability. Health content is lacking in addressing key perceived risks, barriers, and benefits to CRC screening. Developing more appropriate and targeted patient education resources on CRC may improve patient understanding and promote screening.

A meta-analysis of randomized controlled trials of low-volume polyethylene glycol plus ascorbic acid versus standard-volume polyethylene glycol solution as bowel preparations for colonoscopy

BACKGROUND

Standard-volume polyethylene glycol (PEG) gut lavage solutions are safe and effective, but they require the consumption of large volumes of fluid. A new lower-volume solution of PEG plus ascorbic acid has been used recently as a preparation for colonoscopy.

AIM

A meta-analysis was performed to compare the performance of low-volume PEG plus ascorbic acid with standard-volume PEG as bowel preparation for colonoscopy.

STUDY

Electronic and manual searches were performed to identify randomized controlled trials (RCTs) that compared the performance of low-volume PEG plus ascorbic acid with standard-volume PEG as bowel preparation for colonoscopy. After a methodological quality assessment and data extraction, the pooled estimates of bowel preparation efficacy during bowel cleansing, compliance with preparation, willingness to repeat the same preparation, and the side effects were calculated. We calculated pooled estimates of odds ratios (OR) by fixed- and/or random-effects models. We also assessed heterogeneity among studies and the publication bias.

RESULTS

Eleven RCTs were identified for analysis. The pooled OR for preparation efficacy during bowel cleansing and for compliance with preparation for low-volume PEG plus ascorbic acid were 1.08 (95% CI = 0.98-1.28, P = 0.34) and 2.23 (95% CI = 1.67-2.98, P<0.00001), respectively, compared with those for standard-volume PEG. The side effects of vomiting and nausea for low-volume PEG plus ascorbic acid were reduced relative to standard-volume PEG. There was no significant publication bias, according to a funnel plot.

CONCLUSIONS

Low-volume PEG plus ascorbic acid gut lavage achieved non-inferior efficacy for bowel cleansing, is more acceptable to patients, and has fewer side effects than standard-volume PEG as a bowel preparation method for colonoscopy.

Randomized trial of 2-L polyethylene glycol + ascorbic acid versus 4-L polyethylene glycol as bowel cleansing for colonoscopy in an optimal setting

BACKGROUND AND AIM

Prior studies have reported 2-L polyethylene glycol (PEG) plus ascorbic acid (PEG + Asc) is an effective alternative to standard 4-L PEG for bowel preparation before colonoscopy, but they are limited because of some confounders. Therefore, we compared the efficacy, patient compliance, satisfaction, and safety of 2-L PEG + Asc versus 4-L PEG for bowel cleansing in optimal preparation strategies.

METHODS

In this prospective, randomized, single-blind trial, consenting outpatients were randomly assigned to one of two arms. All colonoscopies were scheduled in the morning and cleansing solutions were administered as a split-dose regimen. Bowel-cleansing efficacy in three different segments was measured on a five-point scale with four-point overall grading. Patients' opinions of the preparation regimens were obtained by questionnaire.

RESULTS

There was no significant difference between the 2-L PEG + Asc (159/163; 97.5%) and 4-L PEG (162/164; 98.8%) with respect to the overall success of bowel cleansing (mean difference = -1.3 [-4.1-∞]). Patient compliance, acceptability, and satisfaction were better in the 2-L PEG + Asc arm than the 4-L PEG arm (P < 0.05). Additionally, the incidence of side effects was lower in the 2-L PEG + Asc than the 4-L PEG (overall, 57.7% vs 73.2%, P < 0.05). However, no significant difference was seen in patients' rating of taste.

CONCLUSIONS

In an optimal preparation setting, 2-L PEG + Asc has equal efficacy as a bowel cleanser prior to colonoscopy as 4-L PEG, with the advantages of better patient compliance, satisfaction, and safety.

Public awareness of colorectal cancer screening: knowledge, attitudes, and interventions for increasing screening uptake

Colorectal cancer ranks as one of the most incidental and death malignancies worldwide. Colorectal cancer screening has proven its benefit in terms of incidence and mortality reduction in randomized controlled trials. In fact, it has been recommended by medical organizations either in average-risk or family-risk populations. Success of a screening campaign highly depends on how compliant the target population is. Several factors influence colorectal cancer screening uptake including sociodemographics, provider and healthcare system factors, and psychosocial factors. Awareness of the target population of colorectal cancer and screening is crucial in order to increase screening participation rates. Knowledge about this disease and its prevention has been used across studies as a measurement of public awareness. Some studies found a positive relationship between knowledge about colorectal cancer, risk perception, and attitudes (perceived benefits and barriers against screening) and willingness to participate in a colorectal cancer screening campaign. The mentioned factors are modifiable and therefore susceptible of intervention. In fact, interventional studies focused on average-risk population have tried to increase colorectal cancer screening uptake by improving public knowledge and modifying attitudes. In the present paper, we reviewed the factors impacting adherence to colorectal cancer screening and interventions targeting participants for increasing screening uptake.

2 L versus 4 L of PEG3350 + electrolytes for outpatient colonic preparation: a randomized, controlled trial

BACKGROUND

Low-volume bowel preparations are ideal to ensure patient compliance, thus enabling high-quality examinations to be achieved.

OBJECTIVES

To examine the bowel-cleansing efficacy and patient tolerability of split-dose 2 L PEG3350 + electrolytes (PEG3350e) with 15 mg bisacodyl versus split-dose 4 L PEG3350e.

DESIGN

Single-blinded, noninferiority, randomized, controlled trial.

SETTING

Single site, university-affiliated tertiary care center.

PATIENTS

A total of 325 consecutive patients undergoing elective outpatient colonoscopy.

INTERVENTION

2 L of PEG3350e with 15 mg bisacodyl versus 4 L of PEG3350e, both given in a split-dose fashion.

MAIN OUTCOME MEASUREMENTS

Efficacy and tolerability of a split dose of 2 L of PEG3350e with 15 mg bisacodyl. Efficacy was assessed by using the Boston Bowel Preparation Scale and Ottawa Bowel Preparation Scale. Patient satisfaction and tolerability were assessed by using a short survey.

RESULTS

A total of 325 patients were included in the intention-to-treat analysis (51% male) with a mean ± standard deviation age of 56 ± 11.2 years. No statistically significant difference in cleanliness was found by using the Boston Bowel Preparation Scale (intention-to-treat, P = .381; per-protocol, P = .387) and the Ottawa Bowel Preparation Scale (intention-to-treat, P = .285; per-protocol, P = .334). Participants receiving 2 L of PEG3350e found the preparation easy to consume and were willing to repeat the procedure more often than the 4-L group (P < .001).

LIMITATIONS

Single-center study looking at outpatient colonoscopies; unable to comment on adenoma detection rate.

CONCLUSIONS

Bowel-cleansing efficacy was similar in both the 2-L and 4-L PEG3350e groups; however, patient tolerability and willingness to repeat preparation were statistically greater with the 2 L of PEG3350e with 15 mg bisacodyl regimen.

Comparison of the Efficacy and Tolerability between Same-day Picosulfate and Split-dose Polyethylene Glycol Bowel Preparation for Afternoon Colonoscopy: A Prospective, Randomized, Investigator-blinded Trial

Background/Aims

In the present study, we evaluated the efficacy and tolerability between same-day bowel preparation protocols using 2 sachets of Picosulfate and a 4 L split-dose polyethylene glycol (PEG) bowel preparation for afternoon colonoscopy.

Methods

The study had a single-center, prospective, randomized, and investigator-blinded, non-inferiority design. We evaluated bowel preparation quality according to the Ottawa scale, patient tolerability, compliance, incidence of adverse events, sleep quality, and polyp/adenoma detection rate.

Results

Among the 196 patients analyzed (mean age, 55.3 years; 50.3% men), 97 received the same-day regimen of 2 sachets of picosulfate (group A) and 99 received the 4 L split-dose PEG regimen (group B). The Ottawa score of the total colon was 4.05±1.56 in group A and 3.80±1.55 in group B (P=0.255). The proportion of patients having adequate bowel preparation in the same-day picosulfate group (61.5%) was slightly less than the 4 L PEG group (71.3%); however, the difference was not statistically significant (P=0.133). Tolerability of the group A regimen was superior to that of the group B regimen (P<0.000). The same-day picosulfate regimen was associated with fewer adverse events, such as abdominal bloating (P=0.037) and better sleep quality (P<0.000).

Conclusions

The same-day picosulfate regimen and the 4 L split-dose PEG regimen had similar efficacy in bowel preparation for afternoon colonoscopy. However, the same-day picosulfate regimen was easier to administer, produced fewer adverse events, and enabled better sleep quality.

A low-residue breakfast improves patient tolerance without impacting quality of low-volume colon cleansing prior to colonoscopy: a randomized trial

OBJECTIVES

We compared the efficacy and patient tolerance of two dietary regimens used as an adjunct to standard bowel cleansing in preparation for elective colonoscopy.

METHODS

Our prospective, randomized, single-blind, controlled, noninferiority trial compared two dietary regimens administered the day before colonoscopy. Subjects received low-volume bowel preparation. The primary outcome was efficacy of colon cleansing, rated by the Ottawa bowel preparation scale (OBPS). Patient acceptance of the assigned dietary regimen was assessed as a secondary outcome.

RESULTS

The mean OBPS score for the standard clear-fluid diet group was 4.47, compared with 4.62 for the low-residue breakfast group, meeting criteria for noninferiority. The groups reported similar mean intensity of hunger on a visual analog hunger scale. However, overall satisfaction was higher with the low-residue diet than with the clear-fluid diet.

CONCLUSIONS

A low-residue breakfast on the day before elective colonoscopy does not compromise the overall quality of bowel preparation as compared with a standard clear-fluid diet and is likely to be preferred by patients.

Efficacy and acceptability of sodium picosulphate/magnesium citrate vs low-volume polyethylene glycol plus ascorbic acid for colon cleansing: a randomized controlled trial

AIM

The study compared the efficacy, safety and tolerability of a low-volume picosulphate/magnesium citrate preparation with that of polyethylene glycol plus ascorbic acid (PEG + ASC) in a randomized clinical trial (RCT).

METHOD

A multicentre randomized, single-blinded study was designed. Adult outpatients undergoing colonoscopy received either picosulphate/magnesium citrate (Group 1) or PEG + ASC (Group 2). Bowel cleansing was assessed using the Boston Bowel Preparation Scale (BBPS) and rated as adequate if ≥ 2 in each segment. Patient acceptance, satisfaction and related symptoms were recorded.

RESULTS

Two-hundred and eighty-five patients were included. Preparation was adequate in 75.7% of patients in Group 1 and in 76.5% of patients in Group 2. The mean BBPS scores for the entire colon and for the right colon were comparable between groups. In addition, 97.1% patients in Group 1 and 84.8% in Group 2 reported no or mild discomfort (P < 0.0003) and 97.8% and 83.4% expressed their willingness to repeat the preparation (P < 0.0001). Palatability was better in Group 1, whereas related symptoms occurred more frequently in Group 2. Regardless of which preparation was used, the split regimen was associated with better cleansing compared with the same-day method (OR = 3.39; 95% CI: 1.1-10.4; P = 0.03). Other predictors of poor cleansing were comorbidity, discomfort during preparation and incomplete (< 75%) preparation.

CONCLUSION

Both picosulphate/magnesium citrate and PEG + ASC are effective for bowel preparation. Tolerability and palatability are better for picosulphate/magnesium citrate. A split schedule is associated with higher cleansing quality also for low-volume regimens.

Colonoscopy and colorectal cancer incidence and mortality

There is substantial indirect evidence for the effectiveness of colonoscopy in reducing colorectal cancer incidence and mortality. However, several recent studies have raised questions on the magnitude of effect for right-sided colorectal cancers. Well-documented variation in outcomes when colonoscopy is performed by different groups of endoscopists suggests that the recent emphasis on the quality of the procedures should lead to improved outcomes after colonoscopy including reduction in incidence and mortality due to right-sided colorectal cancers.

Patients' perception of colonoscopy: patients with inflammatory bowel disease and irritable bowel syndrome experience the largest burden

BACKGROUND

Colonoscopy is a frequently performed procedure worldwide with a negative perception, leading to reluctance to undergo the procedure. Perceptions could differ depending on the specific indication for the colonoscopy.

AIMS

To compare patient satisfaction with the colonoscopy procedure between five different patient groups: inflammatory bowel disease (IBD), familial predisposition for cancer, adenoma/carcinoma surveillance, symptoms suggestive of cancer, and irritable bowel syndrome (IBS).

METHODS

A prospective questionnaire study was carried out in two regional hospitals and two tertiary teaching hospitals in the Netherlands. A total of 797 consecutive patients scheduled for colonoscopy between October 2009 and June 2010, 146 (18%) IBD, 153 (19%) adenoma or carcinoma surveillance, 104 (13%) familial predisposition, 280 (35%) symptoms suggestive of cancer, and 114 (14%) IBS-like symptoms, were included. Two questionnaires were administered: one on the day of the procedure and another 6 weeks after the procedure. The main outcome measurements were embarrassment, pain, burden, most burdensome aspect, and overall level of satisfaction.

RESULTS

Patients with IBD and IBS reported significantly more embarrassment and burden from the bowel preparation phase (P=0.040 and 0.018, respectively) and more pain during the colonoscopy procedure (P=0.018). This difference in pain was also observed when adjusting for volume of sedation administered, familiarity with the endoscopist, duration of the colonoscopy, or whether or not an intervention was performed. All patient groups were less satisfied with the procedure at 6 weeks than directly after the colonoscopy; they recalled more embarrassment and burden, but less pain.

CONCLUSION

Patient groups, defined by indication for colonoscopy, experience the colonoscopy procedure differently.

Factors associated with never being screened for colorectal cancer

Colorectal cancer (CRC) screening is underused in the United States, and non-adherence with screening recommendations is high in some populations. This study describes the characteristics of people who have never been screened for CRC. In addition, we use the health belief model to examine the constructs associated with screening behavior. We used data from the 2010 Behavioral Risk Factor Surveillance System (BRFSS) to create three study outcomes: people who have been screened for CRC and are up-to-date with current recommendations, people who have been screened but are not up-to-date, and people who have never been screened. We used multivariate logistic regression modeling to calculate predicted marginal estimates examining the associations between the screening outcomes and demographic and Health Belief Model (HBM) characteristics. Overall 29% of respondents had never been screened for CRC. In the adjusted model, 36.6% of US adults age 50-59 years and 29.1% of US men reported never being screened for CRC. More Asian/Native Hawaiian/Pacific Islander, non-Hispanics (38.2%) reported never being screened than members of other racial and ethnic groups. Nearly 37% of people with less than a high school diploma reported never being screened. We found statistically significant differences among screening outcomes for all demographics and HBM constructs except could not see a doctor because of costs in the last 12 months, where approximately 29% reported no CRC screening. New interventions should focus on those subpopulations that have never been screened for CRC.

Genome-wide identification and validation of a novel methylation biomarker, SDC2, for blood-based detection of colorectal cancer

Aberrant DNA methylation has shown promise as a biomarker for the early detection of cancer. To discover novel genes frequently methylated at an early stage in colorectal cancer (CRC), DNA microarray analysis coupled with enriched methylated DNA was performed in primary tumors and compared with adjacent nontumor tissues of 12 patients with CRC at stages I to IV. Stepwise filtering for candidate selection in microarray data analysis yielded a set of genes that are highly methylated across all CRC tumors and that can be used as a composite biomarker for CRC detection. Verification assay identified the SDC2 gene as a potential methylation biomarker for early CRC detection. In clinical validation in tissues from 139 CRC patients, a much higher level of aberrant SDC2 methylation was measured in most primary tumors (97.8%), compared with corresponding nontumor tissue of CRC patients, irrespective of clinical stage. Clinical validation of SDC2 methylation in serum DNA from CRC patients (n = 131) at stages I to IV and from healthy individuals (n = 125) by quantitative methylation-specific PCR demonstrated a high sensitivity of 87.0% (95% CI, 80.0% to 92.3%) in detecting cancers, with a specificity of 95.2% (95% CI, 89.8% to 98.2%). Importantly, sensitivity at stage I was 92.3%, indicating the potential of SDC2 methylation as a blood-based DNA test for early detection of CRC.

Shared decision-making about colorectal cancer screening: a conceptual framework to guide research

OBJECTIVE

To develop a conceptual framework to guide research on shared decision-making about colorectal cancer (CRC) screening among persons at average risk and their providers.

METHODS

Based upon a comprehensive review of empirical literature and relevant theories, a conceptual framework was developed that incorporated patient characteristics, cultural beliefs, provider/health care system variables, health belief/knowledge/stage of adoption variables, and shared decision-making between patients and providers that may predict behavior. Relationships among concepts in the framework, shared decision-making process and outcomes, and CRC screening behavior were proposed. Directions for future research were presented.

RESULTS

Many of the concepts in the proposed framework have been examined in prior research. However, these elements have not been combined previously to explain shared decision-making about CRC screening.

CONCLUSION

Research is needed to test the proposed relationships and hypotheses and to refine the framework.

PRACTICE IMPLICATIONS

Findings from future research guided by the proposed framework may inform clinical practice to facilitate shared decision-making about CRC screening.

Acceptability of oral iodinated contrast media: a head-to-head comparison of four media

OBJECTIVE

To assess the palatability of iodinated oral contrast media commonly used in abdominopelvic CT and CT colonography (CTC).

METHODS

80 volunteers assessed the palatability of a 20-ml sample of a standard 30 mg ml(-1) dilution of Omnipaque® (iohexol; GE Healthcare, Cork, Ireland), Telebrix® (meglumine ioxithalamate; Guerbet, Aulnay-sous-Bois, France), Gastromiro® (iopamidol; Bracco, High Wycombe, UK) and Gastrografin® (sodium diatrizoate and meglumine diatrizoate; Bayer, Newbury, UK) in a computer-generated random order.

RESULTS

Gastrografin is rated significantly less palatable than the remaining media (p<0.005). Omnipaque and Telebrix are significantly more palatable than Gastromiro. No difference existed between Omnipaque and Telebrix. 39% of participants would refuse to consume the quantities of Gastrografin required for a CTC examination compared with Telebrix (7%) and Omnipaque (9%) (p<0.05).

CONCLUSION

Omnipaque and Telebrix are significantly more palatable than both Gastromiro and Gastrografin, with participants more willing to ingest them in larger quantities as well as being less expensive.

ADVANCES IN KNOWLEDGE

Omnipaque and Telebrix are significantly more palatable iodinated oral contrast media than both Gastromiro and Gastrografin, which has potential implications in compliance with both abdominopelvic CT and CTC.

Gender differences in attitudes impeding colorectal cancer screening

Background

Colorectal cancer screening (CRCS) is the only type of cancer screening where both genders reduce risks by similar proportions with identical procedures. It is an important context for examining gender differences in disease-prevention, as CRCS significantly reduces mortality via early detection and prevention. In efforts to increase screening adherence, there is increasing acknowledgment that obstructive attitudes prevent CRCS uptake. Precise identification of the gender differences in obstructive attitudes is necessary to improve uptake promotion. This study randomly sampled unscreened, screening - eligible individuals in Ontario, employing semi-structured interviews to elicit key differences in attitudinal obstructions towards colorectal cancer screening with the aim of deriving informative differences useful in planning promotions of screening uptake.

Methods

N = 81 participants (49 females, 32 males), 50 years and above, with no prior CRCS, were contacted via random-digit telephone dialing, and consented via phone-mail contact. Altogether, N = 4,459 calls were made to yield N = 85 participants (1.9% response rate) of which N = 4 participants did not complete interviews. All subjects were eligible for free-of-charge CRCS in Ontario, and each was classified, via standard interview by CRCS screening decision-stage. Telephone-based, semi-structured interviews (SSIs) were employed to investigate gender differences in CRCS attitudes, using questions focused on 5 attitudinal domains: 1) Screening experience at the time of interview; 2) Barriers to adherence; 3) Predictors of Adherence; 4) Pain-anxiety experiences related to CRCS; 5) Gender-specific experiences re: CRCS, addressing all three modalities accessible through Ontario’s program: a) fecal occult blood testing; b) flexible sigmoidoscopy; c) colonoscopy.

Results

Interview transcript analyses indicated divergent themes related to CRCS for each gender: 1) bodily intrusion, 2) perforation anxiety, and 3) embarrassment for females and; 1) avoidant procrastination with underlying fatalism, 2) unnecessary health care and 3) uncomfortable vulnerability for males. Respondents adopted similar attitudes towards fecal occult blood testing, flexible sigmoidoscopy and colonoscopy, and were comparable in decision stage across tests. Gender differences were neither closely tied to screening stage nor modality. Women had more consistent physician relationships, were more screening-knowledgeable and better able to articulate views on screening. Men reported less consistent physician relationships, were less knowledgeable and kept decision-making processes vague and emotionally distanced (i.e. at ‘arm’s length’).

Conclusions

Marked differences were observed in obstructive CRCS attitudes per gender. Females articulated reservations about CRCS-associated distress and males suppressed negative views while ambiguously procrastinating about the task of completing screening. Future interventions could seek to reduce CRCS-related stress (females) and address the need to overcome procrastination (males).

Demonstration of a sucrose-derived contrast agent for magnetic resonance imaging of the GI tract

A scaffold bearing eight terminal alkyne groups was synthesized from sucrose, and copies of an azide-terminated Gd-DOTA complex were attached via copper(I)-catalyzed azide-alkyne cycloaddition. The resulting contrast agent (CA) was administered by gavage to C3H mice. Passage of the CA through the gastrointestinal (GI) tract was followed by T1-weighted magnetic resonance imaging (MRI) over a period of 47h, by which time the CA had exited the GI tract. No evidence for leakage of the CA from the GI tract was observed. Thus, a new, orally administered CA for MRI of the GI tract has been developed and successfully demonstrated.

Can mosapride citrate reduce the volume of lavage solution for colonoscopy preparation?

AIM: To evaluate the possibility of reducing the volume of polyethylene glycol (PEG)-electrolyte solution using adjunctive mosapride citrate for colonoscopy preparation.

METHODS: This was a single-center, prospective, randomized, investigator-blinded, non-inferiority study involving 252 patients of both sexes, aged from 20 to 80 years, scheduled for screening or diagnostic colonoscopy in our department. A total of 126 patients was randomized to receive 1.5 L PEG-electrolyte solution plus 15 mg of mosapride (1.5 L group), and 126 received 2 L PEG-electrolyte solution plus 15 mg of mosapride (2 L group). Patients completed a questionnaire on the acceptability and tolerability of the bowel preparation process. The efficacy of bowel preparation was assessed using a 5-point scale based on the Aronchick scale. The primary end point was adequate bowel preparation rates (score of excellent/good/fair) vs (poor/inadequate). Acceptability and tolerability, as well as disease detection, were secondary end points.

RESULTS: A total of 244 patients was included in the analysis. There were no significant differences between the 2 L and 1.5 L groups in age, sex, body mass index, number of previous colonoscopies, and the preparation method used previously. The adequate bowel preparation rates were 88.5% in the 2 L group and 82.8% in the 1.5 L group [95% lower confidence limit (LCL) for the difference = -14.5%, non-inferiority P = 0.019] in the right colon. In the left colon, the adequate bowel preparation rates were 89.3% in the 2 L group and 81.1% in the 1.5 L group (95% LCL = -17.0%, non-inferiority P = 0.066). Compliance, defined as complete (100%) intake of the PEG solution, was significantly higher in the 1.5 L group than in the 2 L group (96.8% vs 85.7%, P = 0.002). The proportion of abdominal distension (none/mild/moderate/severe) was significantly lower in the 1.5 L group than in the 2 L group (36/65/22/3 vs 58/48/18/2, P = 0.040). Within the subgroup who had undergone colonoscopy previously, a significantly higher number of patients in the 1.5 L group than in the 2 L group felt that the current preparation was easier than the previous one (54.1% vs 28.0%, P = 0.001). The disease detection rate was not significantly different between the two groups.

CONCLUSION: Although the 1.5 L group had better acceptability and tolerability, 15 mg of mosapride may be insufficient to compensate for a 0.5-L reduction of PEG solution.

Suture marker lesion detection in the colon by self-stabilizing and unmodified capsule endoscopes: pilot study in acute canine models

BACKGROUND

Capsule endoscopy is a noninvasive method for examining the small intestine. Recently, this method has been used to visualize the colon. However, the capsule often tumbles in the wider colon lumen, resulting in potentially missed pathology. In addition, the capsule does not have the ability to distend collapsed segments of the organ. Self-stabilizing capsule endoscopy is a new method of visualizing the colon without tumbling and with the ability to passively distend colon walls.

OBJECTIVE

To quantitatively compare the detection rate of intraluminal suture marker lesions for colonoscopy by using a custom-modified, self-stabilizing capsule endoscope (SCE); an unmodified capsule endoscope (CE) of the same brand; and a standard colonoscope.

DESIGN

Four mongrel dogs underwent laparotomy and the implantation of 5 to 8 suture markers to approximate colon lesions. Each dog had both capsule endoscopy and self-stabilizing capsule endoscopy, administered consecutively in random order. In each case, the capsule was inserted endoscopically into the proximal lumen of the colon followed by pharmacologically induced colon peristalsis to propel it distally through the colon. Blinded standard colonoscopy was performed by an experienced gastroenterologist after the capsule endoscopies.

SETTING

Experimental study in a live canine model.

SUBJECTS

Four dogs.

INTERVENTION

Laparotomy, capsule endoscopy, colonoscopy.

MAIN OUTCOME MEASUREMENTS

Comparison of the marker detection rate of the SCE to that of the unmodified MiroCam CE and a colonoscope.

RESULTS

The average percentages of the marker detection rate for unmodified capsule endoscopy, self-stabilizing capsule endoscopy, and colonoscopy, respectively, were 31.1%, 86%, and 100% (P < .01), with both self-stabilizing capsule endoscopy and colonoscopy performing significantly better than the unmodified capsule endoscopy.

LIMITATIONS

Acute canine model, suture markings poorly representative of epithelial polyps, limited number of animals.

CONCLUSION

The proposed self-stabilizing capsule endoscope delivered a significant improvement in detection rates of colon suture markings when compared with the unmodified capsule endoscope.

The preference for an endoscopist specific sex: a link between ethnic origin, religious belief, socioeconomic status, and procedure type

BACKGROUND AND AIM

The sex of the physician performing the endoscopic procedure is one of the parameters influencing patient satisfaction. Our aim was to characterize patients' preferences according to their sex, socioeconomic status, and religious beliefs and according to procedure-related variables.

METHODS

All patients undergoing an endoscopic procedure at Sheba Hospital between April 2012 and September 2012 were asked to complete a questionnaire regarding their sex, ethnic background, socioeconomic status, religious practice, and preference for an endoscopist of a specific sex. Questionnaires were included for analysis only when more than 95% of the items were addressed.

RESULTS

A total of 1,009 patients agreed to complete the questionnaires; of these 946 (94% [59% male]) were eligible for inclusion. Most patients (675 [70%]) expressed no preference for sex of the endoscopist, while 234 patients (25%) preferred a same-sex endoscopist, and only 55 (6%) preferred an other-sex endoscopist. Stepwise logistic regression analysis showed that in female patients, lower education (odds ratio [OR] = 1.28), non-Jewish religion (OR = 4.86), orthodox religious practice (OR = 2.28), African or Asian ethnic origin (OR = 2.44), scheduled for colonoscopy (OR = 1.90), and no previous endoscopy experience (OR = 1.88) were all associated with a preference for a same-sex endoscopist.

CONCLUSION

One-quarter of patients preferred the physician performing their examination to be of particular sex. Most of these patients preferred a same-sex endoscopist. Education level, intensity of religious practice, ethnic origin, and type of endoscopic examination were associated with a preference for a same-sex endoscopist. Addressing patients' preferences may improve the atmosphere in the clinical environment, reduce stress, and facilitate better treatment and adherence to endoscopic surveillance programs.

Gene expression anti-profiles as a basis for accurate universal cancer signatures

Background

Early screening for cancer is arguably one of the greatest public health advances over the last fifty years. However, many cancer screening tests are invasive (digital rectal exams), expensive (mammograms, imaging) or both (colonoscopies). This has spurred growing interest in developing genomic signatures that can be used for cancer diagnosis and prognosis. However, progress has been slowed by heterogeneity in cancer profiles and the lack of effective computational prediction tools for this type of data.

Results

We developed anti-profiles as a first step towards translating experimental findings suggesting that stochastic across-sample hyper-variability in the expression of specific genes is a stable and general property of cancer into predictive and diagnostic signatures. Using single-chip microarray normalization and quality assessment methods, we developed an anti-profile for colon cancer in tissue biopsy samples. To demonstrate the translational potential of our findings, we applied the signature developed in the tissue samples, without any further retraining or normalization, to screen patients for colon cancer based on genomic measurements from peripheral blood in an independent study (AUC of 0.89). This method achieved higher accuracy than the signature underlying commercially available peripheral blood screening tests for colon cancer (AUC of 0.81). We also confirmed the existence of hyper-variable genes across a range of cancer types and found that a significant proportion of tissue-specific genes are hyper-variable in cancer. Based on these observations, we developed a universal cancer anti-profile that accurately distinguishes cancer from normal regardless of tissue type (ten-fold cross-validation AUC > 0.92).

Conclusions

We have introduced anti-profiles as a new approach for developing cancer genomic signatures that specifically takes advantage of gene expression heterogeneity. We have demonstrated that anti-profiles can be successfully applied to develop peripheral-blood based diagnostics for cancer and used anti-profiles to develop a highly accurate universal cancer signature. By using single-chip normalization and quality assessment methods, no further retraining of signatures developed by the anti-profile approach would be required before their application in clinical settings. Our results suggest that anti-profiles may be used to develop inexpensive and non-invasive universal cancer screening tests.

Colon cancer screening in women

Colorectal cancer is the third leading cause of cancer-related deaths in women. Colorectal cancer is a preventable disease with accepted screening modalities that have been proven to save lives. As women are more likely than men to develop right-sided colon cancers, colonoscopy is the preferred screening test in women. Currently, women are less likely to undergo colorectal cancer screening than men. Frank discussions addressing the fear or embarrassment of endoscopic screening are important in helping women overcome these barriers. Enhanced education of both practitioners and patients targeted to improve colorectal cancer screening adherence will improve early diagnosis and patient survival.

Preference for colonoscopy versus computerized tomographic colonography: a systematic review and meta-analysis of observational studies

In recent years, colorectal cancer (CRC) screening using computerized tomographic colonography (CTC) has attracted considerable attention. In order to better understand patient preferences for CTC versus colonoscopy, we performed a systematic review and meta-analysis of the available literature. Data sources included published studies, abstracts and book chapters, in any language, with publication dates from 1995 through February 2012, and with prospective or retrospective enrollment of diagnostic or screening patients who had undergone both procedures and explicit assessment of their preference for colonoscopy versus CTC. A predefined algorithm identified eligible studies using computer and hand searches performed by two independent investigators. We used a mixed effects model to pool preference differences (defined as the proportion of subjects who preferred CTC minus the proportion who preferred colonoscopy for each study). Twenty-three studies met inclusion criteria, totaling 5616 subjects. In 16 of these studies, patients preferred CTC over colonoscopy, while colonoscopy was preferred in three studies. Due to the high degree of heterogeneity, an overall pooled preference difference was not calculated. Stratified analysis revealed that studies published in radiology journals (preference difference 0.590 [95 % CI 0.485, 0.694]) seemed more likely than studies in gastroenterology (0.218 [-0.015-0.451]) or general medicine journals (-0.158 [-0.389-0.072]) to report preference for CTC (p<0.001). Studies by radiology authors showed a trend towards stronger preference for CTC compared with studies by gastroenterology authors. Symptomatic patients expressed no preference, but screening patients preferred CTC. There was no difference in preferences between studies using "masked" and "unmasked" preference ascertainment methods. Three studies featuring limited bowel preparations for CTC reported marked preference for CTC. There was no evidence of publication bias, while cumulative and exclusion analysis did not show any temporal trend or dominant study. Limitations included data heterogeneity and preference ascertainment limitations. In conclusion, most included studies reported preference for CTC. On stratified analysis, screening patients preferred CTC while diagnostic patients showed no preference. Studies published in radiology journals showed significantly stronger preference for CTC compared with studies in gastroenterology or general medicine journals.

Comparison of patient acceptance of sodium phosphate versus polyethylene glycol plus sodium picosulfate for colon cleansing in Japanese

BACKGROUND AND AIM

In Japan, patient acceptance of bowel preparation methods before colonoscopy remains unknown. This study was conducted to evaluate the patient acceptance of sodium phosphate (NaP) tablets and polyethylene glycol solution (PEG) with sodium picosulfate.

METHODS

One hundred patients were randomized into one of the following two groups: the NaP tablet first-use group or the PEG with sodium picosulfate first-use group in a crossover design trial. Patient acceptance and incidence of adverse events were evaluated using a questionnaire. Colon-cleansing effectiveness was also evaluated.

RESULTS

Patients' overall impressions of the preparations were significantly different between the NaP tablet (77.9%, 67/86) and PEG with sodium picosulfate (60.5%, 52/86; P = 0.001). Nausea incidence as an adverse event was significantly different between the two regimens (P = 0.03). Colon-cleansing effectiveness was not significantly different between the two regimens.

CONCLUSIONS

The results of this crossover study showed that patient acceptance was similar to those previously reported in a parallel-group comparison. In Japanese patients, preference for and acceptance of NaP tablets was significantly higher than that for PEG with sodium picosulfate solution.

Serial monitoring of the physiological effects of the standard Pico-Salax® regimen for colon cleansing in healthy volunteers

BACKGROUND

Sodium picosulfate⁄magnesium oxide⁄citric acid (Pico-Salax, Ferring Inc, Canada) is used widely in Canada and other countries for colon cleansing before colonoscopy. It is a low-volume osmotic⁄stimulant agent with the potential to deplete intravascular volume and alter electrolyte balance, yet there are little data regarding its effects on these clinically important end points.

OBJECTIVE

To serially measure parameters of intravascular volume and electrolyte status in healthy volunteers over a 24 h period using the standard two-sachet dosing.

METHODS

Twenty volunteers were given one sachet of Pico-Salax at time 0 h and another sachet 5 h later, as per usual bowel cleansing protocol. Subjects were continually monitored during the first 12 h of the study with postural vital signs, serum electrolytes and electrocardiograms obtained at intervals throughout this initial period and again at 24 h postingestion.

RESULTS

No adverse events were reported nor were there any signs of intravascular volume depletion observed. There were decreases in potassium and calcium levels from baseline to 12 h, but these appeared minor and were corrected by 24 h. The proportions of patients with hypermagnesmia at 0 h, 5 h, 12 h and 24 h were 5%, 35%, 35% and 20%, respectively (P<0.05). However, the maximal values were only minimally elevated. Mean serum sodium, phosphate and creatinine levels remained within their respective reference ranges. There was a trend toward an increase in maximum corrected QT intervals from time 0 h (418 ms) to 5 h (430 ms) (P=0.06), but no significant change was seen subsequently at 12 h (419 ms). The subjects tolerated the medication well. The mean number of bowel movements per subject was 8.15 (range four to 15). Subjects consumed a mean (± SD) of 3.49±1.53 L of fluids during the observation period.

CONCLUSIONS

The proportion of individuals with hypokalemia, hypocalcemia and hypermagnesemia following two sachets of Pico-Salax is significant, but the magnitude of the changes was not clinically relevant in this relatively small group, and both calcium and potassium levels normalized at 24 h. Nonetheless, this could have implications in patients with pre-existing electrolyte abnormalities and the safety of dosing with more than two sachets.

Split-dosed MiraLAX/Gatorade is an effective, safe, and tolerable option for bowel preparation in low-risk patients: a randomized controlled study

OBJECTIVES

MiraLAX with Gatorade is a low-volume bowel preparation regimen that has been used widely in community practice and is anecdotally better tolerated than Golytely. Despite its widespread use, there are little data on the efficacy and tolerability of this solution and no safety data in the literature. The primary aim of this study was to compare the efficacy, safety, and tolerability of single-dosed and split-dosed regimens of MiraLAX/Gatorade with Golytely for bowel preparation before colonoscopy.

METHODS

Adults presenting for outpatient colonoscopy were screened for enrollment into this single-blinded randomized controlled trial. Patients with severe cardiac or renal disease and patients with electrolyte abnormalities were excluded. Subjects were randomized into four groups: 4 l Golytely single-dosed (Go-Si), 4 l Golytely split-dosed (Go-Sp), 238 g MiraLAX in 64 oz of Gatorade single-dosed (Mlax-Si), and MiraLAX/Gatorade split-dosed (Mlax-Sp) groups. Laboratory data including complete blood count, comprehensive metabolic panel, and osmolality were collected before the day of bowel preparation and just before the start of colonoscopy. Subjects completed a survey assessing taste and tolerability of the solution. Colonoscopies were recorded using video recording software and de-identified. Colonoscopy videos were evaluated for efficacy of cleansing by two blinded endoscopists. Two validated bowel preparation scales were used to assess bowel cleansing: the Boston Bowel Preparation Scale (BBPS; 0-9 best) and Ottawa Scale (0-14 worst).

RESULTS

A total of 222 patients were evaluated in this study (86.2% male, mean age 59.4). Of these, 57 subjects were randomized to the Go-Si group, 51 to Go-Sp group, 60 to Mlax-Si group, and 54 to Mlax-Sp group. There was no significant difference in age, gender, or timing of colonoscopy between the groups (P>0.05). Mean BBPS scores were: Go-Si=6.07, Go-Sp=8.33, Mlax-Si=6.62, and Mlax-Sp=8.01. Mean Ottawa score for the groups were: Go-Si group=6.77, Go-Sp=4.12, Mlax-Si=6.25, and Mlax-Sp=4.8. Go-Sp resulted in significantly better cleansing than Go-Si (P<0.01). Mlax-Sp resulted in significantly better cleansing than Mlax-Si (P<0.01). There was no significant difference in BBPS between Go-Sp and Mlax-Sp. There were no clinically significant electrolyte changes from baseline in any subject in any group after bowel prep (P>0.05). Subjects rated the taste and overall experience of Mlax/Gatorade preparation better than Golytely (P<0.01). In all, 96.8% of Mlax/Gatorade subjects were willing to repeat the same preparation vs. 75% for Golytely subjects (P<0.01).

CONCLUSIONS

Split-dosed MiraLAX/Gatorade was an effective, safe, and tolerable option for bowel preparation before colonoscopy in the low-risk patients in this study. MiraLAX/Gatorade appears to be more tolerable than Golytely as a bowel cleansing regimen and was the preferred agent by the patients in this study.

The sedation increases the acceptance of repeat colonoscopies

AIM

The aim of this research was to assess how the use of sedation during colonoscopy influences patient anxiety, fear, satisfaction, and acceptance of repeat examinations.

MATERIALS AND METHODS

A prospective case-control study quantifying the anxiety and fears of patients appointed for colonoscopy, comparing patients who had undergone previous colonoscopies with sedation (cases) with patients who had undergone previous colonoscopies without sedation and patients who had never had a colonoscopy before (controls). Following the examination, patients answered a satisfaction survey and were asked whether they would be willing to undergo future colonoscopies.

RESULTS

The study included 2016 patients (average age 50.05 ± 14.44 years; 47% men). Of these, 1270 patients (63%) were undergoing colonoscopy for the first time and 746 (37%) had undergone the procedure before; in the latter group, 313 patients (42%) had been provided sedation, whereas 433 (58%) had not. Patients who had been sedated for prior colonoscopies assigned significantly lower scores than patients who had undergone previous colonoscopies without sedation and those undergoing the procedure for the first time both in the anxiety survey (3.3 ± 2.5 vs. 7.5 ± 2.8 vs. 10.3 ± 3.5; P<0.01) and in the fears survey (7.1 ± 3.0 vs. 14 ± 2.8 vs. 20.3 ± 4.5; P<0.01). Satisfaction survey scores were significantly higher among sedated patients than among nonsedated patients (22.8 ± 2.7 vs. 18.6 ± 2.3). The percentage of sedated patients who would be willing to undergo colonoscopy again was significantly higher than that of nonsedated patients (70 vs. 25%; P<0.001).

CONCLUSION

Sedation reduces the anxiety and fear of undergoing a repeat colonoscopy and improves both patient satisfaction and the acceptability of future procedures.

Gastroenterology and the provision of care to Panjabi patients in the UK

Panjabi is spoken by 1.3 million people in the UK. It is the second most common language used in the country and is the first choice of 75% of Panjabis. It is becoming more common. For many patients it forms part of the barrier which limits access to gastrointestinal services. The provision of appropriate support services is woeful and yet seldom leads to formal complaints. This review considers the impact of gastrointestinal disorders on the Panjabi community and assesses some of the interventions that could be developed to ensure equity of care.

Randomized Trial of Gatorade/Polyethylene Glycol With or Without Bisacodyl and NuLYTELY for Colonoscopy Preparation

OBJECTIVES:

We assessed the safety, efficacy, and tolerability of a new preparation of Gatorade and polyethylene glycol (PEG) for colonoscopy with or without bisacodyl compared with NuLYTELY.

METHODS:

We performed an investigator-blinded, placebo-controlled, randomized trial of 64 oz of Gatorade and 306 g of PEG (G/PEG) with or without 10 mg of bisacodyl and NuLYTELY. A total of 600 outpatients consumed their preparation the day before a morning colonoscopy. The primary endpoint was colon cleanliness assessed by the Boston Bowel Preparation Scale (BBPS). Tolerability was assessed using a subject questionnaire, and safety was assessed from a basic metabolic profile drawn before the colonoscopy.

RESULTS:

Adding bisacodyl to G/PEG caused more abdominal bloating/cramps (P<0.01) and did not result in a cleaner colon (P=0.66) compared with G/PEG without bisacodyl. The BBPS scores in both the G/PEG arms and NuLYTELY arm were not significantly different (P=0.19). Compared with subjects in the NuLYTELY arm, subjects in the G/PEG without bisacodyl arm had less nausea (P<0.04), vomiting (P<0.02), abdominal pain (P<0.02), bloating (P<0.005), difficulty drinking the liquid (P<0.0001), and found the overall preparation easier to tolerate (P<0.0001). Subjects in the combined G/PEG arms had a lower serum sodium (P<0.0007), chloride (P<0.007), and BUN (P<0.0001) levels than those in the NuLYTELY arm, but this did not cause any clinical symptoms.

CONCLUSIONS:

Bisacodyl added to G/PEG for colon lavage caused more side effects and did not result in a cleaner colon. The G/PEG preparations cleansed the colon as well as NuLYTELY, were far better tolerated, and were equally safe.

Efficacy of mosapride citrate with polyethylene glycol solution for colonoscopy preparation

AIM: To evaluate the efficacy and safety of adjunctive mosapride citrate for bowel preparation before colonoscopy.

METHODS: We conducted a randomized, double-blind, placebo-controlled study with mosapride in addition to polyethylene glycol (PEG)-electrolyte solution. Of 250 patients undergoing colonoscopy, 124 were randomized to receive 2 L PEG plus 15 mg of mosapride citrate (mosapride group), and 126 received 2 L PEG plus placebo (placebo group). Patients completed a questionnaire reporting the acceptability and tolerability of the bowel preparation process. The efficacy of bowel preparation was assessed by colonoscopists using a 5-point scale based on Aronchick’s criteria. The primary end point was optimal bowel preparation rates (scores of excellent/good/fair vs poor/inadequate).

RESULTS: A total of 249 patients were included in the analysis. In the mosapride group, optimal bowel preparation rates were significantly higher in the left colon compared with the placebo group (78.2% vs 65.6%, P < 0.05), but not in the right colon (76.5% vs 66.4%, P = 0.08). After excluding patients with severe constipation, there was a significant difference in bowel preparation in both the left and right colon (82.4% vs 66.7%, 80.8% vs 67.5%, P < 0.05, P < 0.01). The incidence of adverse events was similar in both groups. Among the subgroup who had previous colonoscopy experience, a significantly higher number of patients in the mosapride group felt that the current preparation was easier compared with patients in the placebo group (34/72 patients vs 24/74 patients, P < 0.05).

CONCLUSION: Mosapride citrate may be an effective and safe adjunct to PEG-electrolyte solution that leads to improved quality of bowel preparation, especially in patients without severe constipation.

Evaluation of patient satisfaction of an outpatient colonoscopy service in an asian tertiary care hospital

Aim. To evaluate patient satisfaction towards an outpatient colonoscopy service and analyze areas of dissatisfaction for potential improvement. Method. Consecutive patients attending the outpatient diagnostic colonoscopy service in University of Malaya Medical Centre between 1st February and 31th July 2010 were interviewed using a questionnaire modified from the modified Group Health Association of America-9 (mGHAA-9) questionnaire. Favorable/unfavorable responses to each question, contribution of each question to unfavorable responses, and effect of waiting times on favorable/unfavorable response rates were analyzed. Results. Interview was carried out on 426 patients (52.1% men). Mean age ± standard deviation was 61.3 ± 12.9 years old. Mean waiting times for colonoscopy appointment and on colonoscopy day were 3.8 ± 2.7 months and 1.1 ± 0.8 hours, respectively. The main factors that contributed to unfavorable responses were bowel preparation followed by waiting times for colonoscopy appointment and on colonoscopy day (32.3%, 27.5%, and 19.6%, resp.). Favorable responses diminished to undesirable levels when waiting times for colonoscopy appointment and on colonoscopy day exceeded 1 month and 1 hour, respectively. Conclusion. Bowel preparation and waiting times were main factors for patient dissatisfaction. Waiting times for colonoscopy appointment and on colonoscopy day should not exceed 1 month and 1 hour, respectively, to maintain acceptable levels of patient satisfaction.