Quality of colonoscopy performed by medical or surgical specialists and trainees in five Australian hospitals

BACKGROUND

Ensuring colonoscopy procedure quality is vital to the success of screening and surveillance programmes for bowel cancer in Australia. However, the data on the performance of quality metrics, through adequate adenoma detection, bowel preparation, and procedure completion rates, in the Australian public sector is limited. Understanding these can inform quality improvement to further strengthen our capacity for prevention and early detection of colorectal cancer.

AIM

To determine the quality of colonoscopy in Australian teaching hospitals and their association with proceduralist specialty, trainee involvement, and location.

METHODS

We retrospectively evaluated 2443 consecutive colonoscopy procedure reports from 1 January to 1 April, 2018 from five public teaching tertiary hospitals in Australia (median 60 years old, 49% male). Data for bowel preparation quality, procedure completion rates, and detection rates of clinically significant adenomas, conventional adenomas, and serrated lesions was collected and compared to national criteria for quality in colonoscopy. Participating hospital, proceduralist specialty, and trainee involvement indicators were used for stratification. Data was analysed using Chi-squared tests of independence, Mann-Whitney U, One-way ANOVA, and multivariate binary logistic regression.

RESULTS

Fifty-two point two percent (n = 1276) and 43.3% (n = 1057) were performed by medical and surgical proceduralists respectively, whilst 29.8% (n = 728) involved a trainee. Inadequate bowel preparation affected 7.3% of all procedures. The procedure completion rate was 95.1%, which increased to 97.5% after adjustment for bowel preparation quality. The pooled cancer, adenoma, and serrated lesion detection rates for all five hospitals were 3.5%, 40%, and 5.9% respectively. Assessed hospitals varied significantly by patient age (P < 0.001), work-force composition (P < 0.001), adequacy of bowel preparation (P < 0.001), and adenoma detection rate (P < 0.001). Two hospitals (40%) did not meet all national criteria for quality, due to a procedure completion rate of 94.5% or serrated lesion detection rate of 2.6%. Although lower than the other hospitals, the difference was not significant. Compared with surgical specialists, procedures performed by medical specialists involved older patients [65 years (inter-quartile range, IQR 58-73) vs 64 years (IQR 56-71); P = 0.04] and were associated with a higher adenoma detection rate [odds ratio (OR) 1.53; confidence interval: 1.21-1.94; P < 0.001]. Procedures involving trainee proceduralists were not associated with differences in the detection of cancer, adenoma, or serrated lesions, compared with specialists, or according to their medical or surgical background. On multivariate analysis, cancer detection was positively associated with patient age (OR 1.04; P < 0.001) and negatively associated with medical compared to surgical proceduralists (OR 0.54; P = 0.04). Conventional adenoma detection rates were independently associated with increasing patient age (OR 1.04; P < 0.001), positively associated with medical compared to surgical proceduralists (OR 1.41; P = 0.002) and negatively associated with male gender (OR 0.53; P < 0.001).

CONCLUSION

Significant differences in the quality of colonoscopy in Australia exist, even when national benchmarks are achieved. The role of possible contributing factors, like procedural specialty and patient gender need further evaluation.

Impact of food challenge on local oesophageal immunophenotype in eosinophilic oesophagitis

BACKGROUND

Eosinophilic oesophagitis (EoE) is caused by the ingestion of food antigens. Dietary avoidance can result in clinical and histological remission, while food reintroduction can cause recurrence. It is uncertain if food antigen processing and immune activation occurs locally, in the oesophagus. Therefore, we performed a comparative study of the density of cell surface proteins (known to be involved with antigen presentation) on oesophageal tissue prior to, and following food antigen induced disease recurrence. A secondary aim was to consider novel biomarkers.

METHOD

Adult patients with a diagnosis of EoE, who had achieved histological remission with an elimination diet (<15 eosinophils per high power field at oesophageal biopsy), and who underwent food challenge with proven recurrence were included. Immunohistochemistry/immunofluorescence for CD1a, CD3, CD28, CD40, CD69, CD80, CD138, CXCR3 and HLA-DR was performed. Staining intensity of each biomarker (pixels/mm² ) was quantified by semi-automated analysis (Studio-FL software).

RESULTS

Fourteen cases of EoE (pre and post food challenge), 6 GORD and 5 healthy controls were included. HLA-DR, CD3, CD28, CD40 and CD 138 significantly increased with food reintroduction (P = <0.05). CD1a, CD 69, CD 80 and CXCR3 did not measurably change.

CONCLUSION

The presence of cell surface proteins typically associated with antigen presentation (following food antigen induced recurrence) suggests immune activation occurs in the oesophagus, and the relative lack of langerhans cells (CD1a) may indicate this cell type is unimportant. The cell surface protein CD 138 increases with disease recurrence, is not elevated in GORD or healthy controls, and has promise as a biomarker.

Rainwater harvesting in schools in Taiwan: system characteristics and water quality

In order to understand the current status of rainwater harvesting (RWH) practices in Taiwan's schools, a study was carried out to examine the RWH system performance, water usage, and water quality in these sites. A total of 29 schools in various regions were selected for this investigation, including 7 in the northern, 7 in the central, 8 in the southern, and 7 in the eastern regions of Taiwan. Water quality indicators tested were: pH, temperature, conductivity, oxidation-reduction potential, suspended solid, total organic carbon, fecal coliform, and total coliform. From this study, it was found that RWH systems in these sites generally had two different designs: one that collected rainwater only, and one that collected both rainwater and grey water. From statistical analysis, it was found that water quality indicators such as suspended solids, total organic carbon, and fecal coliform were significantly affected by the water source and site location. Fecal coliforms in most of the sites we studied were high and not qualified for toilet flushing. The average water retention time of 2.4 months was long and considered to be the main reason to cause high fecal coliform counts. Finally, the benefit analysis was conducted to evaluate economic feasibility of rainwater harvesting for these schools. It turned out that 20% of them were able to gain economic benefits from using rainwater.

Remediation of PCE-contaminated aquifer by an in situ two-layer biobarrier: laboratory batch and column studies

The industrial solvent tetrachloroethylene (PCE) is among the most ubiquitous chlorinated compounds found in groundwater contamination. The objective of this study was to develop an in situ two-layer biobarrier system consisting of an organic-releasing material layer followed by an oxygen-releasing material layer. The organic-releasing material, which contained sludge cakes from a domestic wastewater treatment plant, is able to release biodegradable organics continuously. The oxygen-releasing material, which contained calcium peroxide, is able to release oxygen continuously upon contact with water. The first organic-releasing material layer was to supply organics (primary substrates) to reductively dechlorinate PCE in situ. The second oxygen-releasing material layer was to release oxygen to aerobic biodegrade or cometabolize PCE degradation byproducts from the first anaerobic layer. Batch experiments were conducted to design and identify the components of the organic and oxygen-releasing materials, and evaluate the organic substrate (presented as chemical oxygen demand (COD) equivalent) and oxygen release rates from the organic-releasing material and oxygen-releasing materials, respectively. The observed oxygen and COD release rates were approximately 0.0368 and 0.0416 mg/d/g of material, respectively. A laboratory-scale column experiment was then conducted to evaluate the feasibility of this proposed system for the bioremediation of PCE-contaminated groundwater. This system was performed using a series of continuous-flow glass columns including a soil column, an organic-releasing material column, two consecutive soil columns, and an oxygen-releasing material column, followed by two other consecutive soil columns. Anaerobic acclimated sludges were inoculated in the first four columns, and aerobic acclimated sludges were inoculated in the last three columns to provide microbial consortia for contaminant biodegradation. Simulated PCE-contaminated groundwater with a flow rate of 0.25 L/d was pumped into this system. Effluent samples from each column were analyzed for PCE and its degradation byproducts. Results show that up to 99% of PCE removal efficiency was obtained in this passive system. Thus, the biobarrier treatment scheme has the potential to be developed into an environmentally and economically acceptable remediation technology for the in situ treatment of PCE-contaminated aquifer.

Increased toxicity of textile effluents by a chlorination process using sodium hypochlorite

Chlorinated textile effluents were tested for their toxicity using different bioassays. These assays were the Microtox assay, daphnia (Daphnia similis) 48-hr survival test, medaka embryo 14-day and juvenile 96-hr survival tests, and tilapia (Oreochromis mossambicus) juvenile 96-hr survival test. By comparing the results of toxicity tests on water samples collected at the instream prior to the chlorination process and at the outlet of the wastewater treatment facility, we found that wastewater toxicity was obviously increased by chlorination using NaOCl as the oxidant, as evidenced by the different bioassays used. Because no significant difference was observed in water chemistry, such as pH, DO, and conductivity, the induced-toxicity may be partially attributable to residue chlorine or other chlorinated compounds generated by chlorination. Future studies are warranted to identify the cause of the increase in the textile wastewater toxicity.

Predicting soil-water partition coefficients for Hg(II) from soil properties

The metal adsorption characteristics for fifteen Taiwan soils by Hg(II), were evaluated using pH as the major variable. The soil samples were thoroughly characterized for their physical chemical properties and composition, particularly organic matter and metal oxides. The adsorption of Hg(II) increased with increasing pH between pH 2.5 and 5.5, whereas the adsorption significantly decreased above around pH 5.5. Below pH 5.5, greater adsorption was found for soils with a higher organic matter content at constant pH and metal concentration. To better understand the mechanism of adsorption, the experimental results for Hg (II) were tested in a partition coefficient model to relate the adsorption of the Hg(II) by the different soils with soil components: organic matter, iron oxide, aluminium oxide and manganese oxide. This model was not successful when applied to measurements at the differing natural soil pHs because of the importance of pH. At pH greater than 5.5 the model fails because of the complexation of Hg by the dissolved organic matter. However, partition coefficients obtained from experimental data were highly correlated with those calculated for a partition coefficient between mercury and organic matter alone at lower pH. Normalization of the partition coefficients, Kd, for the organic matter content of the soils, Kom, greatly improved the correlation between the partition coefficient and pH under pH 5.5 (R2 increased from 0.484 to 0.716). This suggests that the surficial adsorption sites are principally due to organic matter for pH less than 5.5. For the 24-hour equilibration period employed, diffusion of Hg through this superficial organic matter coating to underlying sorptive materials, including metal oxides, is not important in the partitioning of Hg. At pH above 5, a decrease of mercury adsorption with increasing solution pH was also found. This result may be explained in part by the complexation of mercury by soil dissolved organic matter whose concentration increased with increasing pH.

The effect of hydration on adsorption and desorption of heavy metals in soils

Cr, Ni, and Cd adsorption-desorption on five characterized Taiwan soils was studied. The potential for toxicity and the fate of metals in the soils is dependent upon the ability of the metals to desorb into the aqueous phase. To simulate field conditions, the soils were subjected to wet-dry cycles. The amount and rate of desorption was found to decrease with increasing number of cycles. The wet-dry cycle effect in the desorption of metals from soils is related to the soil composition, with desorption being easiest from sandy soil with low organic content. The desorption process is much slower than adsorption process. More than 95% of each metal adsorption takes place within one hour, and the amount of metal adsorbed from solution reached equilibrium in one day. In contrast, less than 20% metal desorption could be attained after 3 days each of four wet-dry cycles for Cr, Ni, and Cd.

Metal contents of fish from cultureponds near scrap metal reclamation facilities

Milkfish (Chanos chanos) from four fish-culture ponds adjacent to different metal recovery facilities along the Er-Jen River area, Tainan, Taiwan, were sampled to determine their metal contents. Chemical analysis showed that fish tissue contained different concentrations of Cu: 0.71-6.37 micrograms/g, Pb: ND (not detectable) approximately 41.04 micrograms/g, Cd: ND approximately 0.41 microgram/g, Al: 6.75-64.11 micrograms/g, Ni: 0.062-0.504 microgram/g and Zn: 16.11-41.86 micrograms/g. The average concentrations of Cu, Al, Zn, Cd and Pb in fish samples from some of the ponds were significantly higher than those from the reference pond. In addition, there were variations in metal concentrations of fish collected from different ponds. Pond D had the highest mean values of Cu, Cd and Zn, and Pond B of Al and Pb. Further investigations are needed to determine the source of metal contamination in the fish.

Effect of early exposure of flutamide on subsequent growth of transplantable rat prostatic tumor (dunning R-3327)

Rat transplantable prostatic tumors (Dunning R-3327) were treated with flutamide before tumors grew palpable, in order to examine the effect of short term treatment of antiandrogen for prostatic cancer in latent period on the growth after appearance of tumor. Flutamide delayed an appearance of the tumor nodule and retarded the growth rate in proportion as treatment began earlier. Flutamide also reduced final tumor volume. Flutamide-treated tumors histologically consisted of small or dilated glandular structure with an increase in stromal area, but androgen receptors were preserved. Flutamide-treated tumor showed slow growth with androgen sensitivity when transplanted to intact rats, showing prolonged influences of antiandrogen on tumor growth. There was no significant difference between flutamide-treated and control groups in weight of accessory sex organs and serum androgen or estrogen levels. In conclusion, flutamide treatment may retard an appearance of prostatic cancer concomitant in benign prostatic hyperplasia.

True three-dimensional cone-beam reconstruction (TTCR) algorithm

A true three-dimensional cone-beam reconstruction (TTCR) algorithm for direct volume image reconstruction from 2-D cone-beam projections is developed for the complete sphere geometry. The algorithm is derived from the parallel-beam true three-dimensional reconstruction (TTR) algorithm and is based on the modified filtered backprojection technique, which uses a set of 2-D space-invariant filters. The proposed algorithm proved to be superior in spatial resolution to the parallel-beam TTR algorithm and to offer better computational efficiency.