Risk factors for biopsy-proven advanced non-alcoholic fatty liver disease in the Veterans Health Administration

BACKGROUND

With its increasing incidence, nonalcoholic fatty liver disease (NAFLD) is of particular concern in the Veterans Health Administration (VHA).

AIMS

To evaluate risk factors for advanced fibrosis in biopsy-proven NAFLD in the VHA, to identify patients at risk for adverse outcomes.

METHODS

In randomly selected cases from VHA databases (2005-2015), we performed a retrospective case-control study in adults with biopsy-defined NAFLD or normal liver.

RESULTS

Of 2091 patients reviewed, 399 met inclusion criteria. Normal controls (n = 65) had normal liver function. The four NAFLD cohorts included: NAFL steatosis (n = 76), nonalcoholic steatohepatitis (NASH) without fibrosis (n = 68), NAFLD/NASH stage 1-3 fibrosis (n = 82), and NAFLD/NASH cirrhosis (n = 70). NAFLD with hepatocellular carcinoma (HCC) was separately identified (n = 38). Most patients were older White men. NAFLD patients with any fibrosis were on average severely obese (BMI>35 kg/m² ). Diabetes (54.4%-79.6%) and hypertension (85.8%-100%) were more common in NAFLD with fibrosis or HCC. Across NAFLD, 12.3%-19.5% were enrolled in diet/exercise programs and 0%-2.6% had bariatric surgery. Hispanics exhibited higher rates of NASH (20.6%), while Blacks had low NAFLD rates (1.4%-11.8%), particularly NAFLD cirrhosis and HCC (1.4%-2.6%). Diabetes (OR 11.8, P < .001) and BMI (OR 1.4, P < .001) were the most significant predictors of advanced fibrosis.

CONCLUSIONS

In the VHA, diabetes and severe obesity increased risk for advanced fibrosis in NAFLD. Of these patients, only a small proportion (~20%) had enrolled in diet/exercise programs or had bariatric surgery (~2%). These results suggest that providers should focus/tailor interventions to improve outcomes, particularly in those with diabetes and severe obesity.

Comorbidity, age and stage at diagnosis in colorectal cancer (CRC)

6554

Background: Stage at diagnosis is a crucial predictor of outcome in CRC. The purpose of this study is to determine if comorbidity and age affect the stage at which CRC is diagnosed. Identifying variables that influence stage might improve outcomes in CRC. Due to frequent contact with the health care system, we hypothesize that patients with greater comorbidity and older age are more likely to be diagnosed with early-stage disease. Methods: We present data from two distinct patient populations: using the Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) database, we identified CRC patients treated at 15 Veterans Administration (VA) hospitals from 2003-present. We also identified CRC patients treated from 2003-present at 10 non-VA, fee-for-service (FFS) practices in North and South Carolina. Data were abstracted by retrospective chart review. Comorbidity was calculated by the Charlson comorbidity index (CCI) with high comorbidity defined as CCI =3. Older age was defined as age =70 years. Data were analyzed using logistic regression where the odds of late stage at diagnosis were modeled as influenced by older age, high CCI, and race. The analysis included estimation of adjusted and unadjusted odds ratios. Results: 347 VA and 282 FFS patients were included. 98% VA vs 50% FFS were male; 43% VA vs 27% FFS were aged =70; 56% VA vs 70% FFS were white; 26% VA vs 44% FFS presented with metastatic CRC; and 21% VA vs 6% FFS had a CCI =3. In both patient populations, regression analysis showed that older age, high CCI and white race were not significant predictors of stage at diagnosis. VA 95% confidence intervals (CI's) were 0.52–1.41 (age =70), 0.50–1.75 (CCI =3), and 0.42–1.11 (white race). FFS 95% CI's were 0.52–1.53 (age =70), 0.36–2.78 (CCI =3), and 0.74–2.11 (white race). Broader 95% CI's in the FFS analysis were due to smaller sample size. Conclusions: In CRC patients, age and comorbidity were not related to stage at diagnosis. The findings are similar whether the patients were treated in a fee-for-service or VA health system. While older age and greater illness might provide more contact with the health care system, this exposure did not result in earlier diagnosis of CRC. Future studies will examine the impact of comorbidity on CRC treatment and survival.

No significant financial relationships to disclose.

Improvement of gastroesophageal reflux disease after initiation of a low-carbohydrate diet: five brief case reports

The 5 individuals described in these case reports experienced resolution of GERD symptoms after self-initiation of a low-carbohydrate diet. Their observations suggest that carbohydrate restriction may have contributed to their symptom relief. However, this conclusion is confounded by concurrent reduction of caffeine intake in 3 of the individuals and reduction of acidic and high-osmolal food intake in all of them. Observations from some of these individuals suggest that carbohydrates may be a precipitating factor for GERD symptoms and that other classic exacerbating foods such as coffee and fat may be less pertinent when a low-carbohydrate diet is followed. However, these conclusions are preliminary. These findings primarily suggest that prospective research should be performed on the effect of low-carbohydrate diets on GERD symptoms. Trials that control for all of the confounders mentioned above and that contain objective endpoints are needed to further investigate these issues.

Clinical and demographic predictors of Barrett's esophagus among patients with gastroesophageal reflux disease: a multivariable analysis in veterans

BACKGROUND

The subgroup of patients with gastroesophageal reflux disease (GERD) that should undergo endoscopy to rule out Barrett's esophagus (BE) has not been well defined.

GOALS

To examine demographic and clinical variables predictive of BE before endoscopy.

STUDY

A validated GERD questionnaire was administered to 107 patients with biopsy-proven BE and to 104 patients with GERD but no BE shown by endoscopy. Frequent symptoms were defined as symptoms that occurred at least once or more each week. Severity of symptoms was rated on a scale from 1 to 4 (mild to very severe). Univariate analysis and multivariable logistic regression were performed to determine whether demographic characteristics and the duration, severity, and frequency of GERD symptoms were associated with the identification of BE.

RESULTS

Eighty-five percent of the GERD patients and 82% of the BE patients completed the questionnaire. There was no difference between the groups in terms of race, gender, or proton pump inhibitor use. The BE patients were older (median age, 64 vs. 57 years, p = 0.04). In multivariable logistic regression, an age of more than 40 years ( p = 0.008), the presence of heartburn or acid regurgitation ( p = 0.03), and heartburn more than once a week ( p = 0.007) were all independent predictors of the presence of BE. Interestingly, patients with BE were less likely to report severe GERD symptoms ( p = 0.0008) and nocturnal symptoms ( p = 0.03). Duration of symptoms, race, alcohol, and smoking history were not associated with BE.

CONCLUSIONS

Upper endoscopy should be performed in GERD patients more than 40 years of age who report heartburn once or more per week. The severity of symptoms and the presence of nocturnal symptoms are not reliable indicators of the presence of BE.

A prospective evaluation of health-related quality of life after ileal pouch anal anastomosis for ulcerative colitis

OBJECTIVES

The ileal pouch anal anastomosis is a safe and effective procedure but is also associated with pouchitis, small bowel obstruction, and incontinence. We prospectively evaluated the health-related quality of life using generic and disease-specific measures in a cohort of patients with ulcerative colitis undergoing ileal pouch anal anastomosis.

METHODS

Health-related quality of life measures included the Time Trade-off, Rating Form of IBD Patient Concerns, and the Short-Form 36. Assessments occurred preoperatively and 1, 6, and 12 months postoperatively.

RESULTS

Time Trade-off scores had significantly improved at the 1-month postoperative assessment and approached perfect health at the 12-month postoperative assessment. The Rating Form of IBD Patient Concerns revealed a significant reduction in patient concerns at 1 month, and this difference persisted at 6 and 12 months. Seven of the eight subscales of the Short-Form 36 revealed improved health-related quality of life postoperatively.

CONCLUSIONS

Health-related quality of life improved after ileal pouch anal anastomosis when assessed with both generic and disease-specific measures. Improvements were observed as early as 1 month postoperatively. These results may guide patients and physicians as they consider and prepare for the impact of ileal pouch anal anastomosis.

Factors associated with acceptance and full publication of GI endoscopic research originally published in abstract form

BACKGROUND

Many abstracts submitted to annual scientific meetings never come to full publication in peer-reviewed journals. The objective of this study was to determine factors associated with the fate of endoscopic research abstracts submitted to the annual scientific meeting of the American Society for Gastrointestinal Endoscopy (ASGE).

METHODS

All abstracts (n = 461) submitted to the annual meeting of the ASGE in May of 1994 were retrospectively reviewed. The following databases were searched for evidence of publication of abstracts in full-manuscript form: Medline, HealthSTAR, Current Contents, CINHAL, and Cancerlit. All abstracts were reviewed between May 4, 1998 and June 30, 1998. Univariate and multivariate analysis were performed to determine the association between abstract characteristics and acceptance for presentation at the meeting and for publication.

RESULTS

Fifty-five percent (247/451) of submitted abstracts were accepted for presentation. In univariate analysis, pediatric studies, prospective studies, randomized studies, and studies from university-affiliated medical centers (UAMC), were more likely to be accepted for presentation (p < 0.05). In multivariate analysis, the variables: pediatric studies (p = 0.01), prospective studies (p = 0.005), randomized studies (p = 0.06), and studies from UAMC (p = 0.01) predicted acceptance of abstracts for presentation at the meeting. The overall publication rate was 25.1%. The publication rates 1, 2, 3, and 4 years after the meeting were 6.7%, 16.2%, 22.8%, and 25.1%, respectively. Multivariate Cox proportional hazards analysis showed that accepted abstracts (p = 0.0003) studies reporting positive results (p = 0.0015), and studies from outside the United States (p = 0.036) were more likely to be published in manuscript form.

CONCLUSIONS

The overall publication rate of abstracts reporting endoscopic research is 25%, lower than that in any published report from other medical societies. Abstracts from the United States were less likely to be published in full-manuscript form. Although there was no positive outcome bias for acceptance of abstracts for presentation at the meeting, there was bias toward publication of statistically significant results. Further investigations are warranted to determine the variation in the publication of research results according to country of origin and to determine factors that hinder publication of GI endoscopic research in manuscript form.

Surveillance issues in inflammatory bowel disease: ulcerative colitis

This review article on the surveillance of patients with ulcerative colitis provides an overview of the criteria for evaluating screening and surveillance programs and applies the criteria to the available evidence to determine the effectiveness of the surveillance of patients with ulcerative colitis. We examine the clinical outcomes associated with surveillance, the additional clinical time required to confirm the diagnosis of dysplasia and cancer, compliance with surveillance and follow-up, and the effectiveness of the individual components of a surveillance program, including colonoscopy and pathologist's interpretation. The disability associated with colectomy is considered, as are the cost and acceptability of surveillance programs. Patients with long-standing ulcerative colitis are at risk for developing colorectal cancer. Recommended surveillance colonoscopy should be supported. New endoscopic and histopathologic techniques to improve the identification of high-risk patients may enhance the effectiveness and cost-effectiveness of surveillance practices.

Economic considerations in the treatment of gastroesophageal reflux disease: a review

Gastroesophageal reflux disease is a common problem. Most patients with erosive GERD require long-term treatment, without which relapse is common. The cost of ongoing medical care for GERD is substantial, and patients with symptomatic GERD have impaired quality of life. Treatment strategies for GERD should aim to improve patient outcome at a reasonable cost. Cost-effectiveness methodology facilitates the integration of costs and patient outcomes, enabling the clinician to choose the most cost-effective therapy in a variety of clinical circumstances. The published studies reviewed in this paper show that proton pump inhibitors are the most cost-effective initial and maintenance medical therapy for GERD under most circumstances. However, variations in drug acquisition costs, such as may occur in managed care practice settings, may lead to H2-receptor antagonists being preferred under some circumstances. In the long-term management of GERD, laparoscopic surgery is effective, but its high initial cost makes it less cost-effective than proton pump inhibitors in the early treatment years. Also, recent data suggest that the long-term morbidity is higher than previously suspected. Finally, appropriate application of cost-effectiveness analyses to clinical practice requires critical appraisal of model design and the perspective adopted. The purpose of this article is to describe the interpretation and application of the results of cost-effectiveness analyses in clinical practice, and to examine the published literature on the cost-effectiveness of treatment options for GERD.

Health-related quality of life and severity of symptoms in patients with Barrett's esophagus and gastroesophageal reflux disease patients without Barrett's esophagus

OBJECTIVES

The aims of this study were: 1) to compare the health-related quality of life (HRQL) of patients with Barrett's esophagus (BE) to that of patients with GERD who did not have BE; 2) to compare HRQL of gastroesophageal reflux disease (GERD) patients to that of normative data for the US general population; and 3) to examine the impact of GERD symptom frequency and severity on HRQL.

METHODS

The SF-36 and a validated GERD questionnaire were administered to 107 patients with biopsy-proven BE and to 104 patients with GERD but no BE by endoscopy. Frequent symptoms were defined as symptoms that occurred at least once weekly. Severity of symptoms was rated on a scale from 1 to 4 (mild to very severe).

RESULTS

In all, 85% of the GERD patients and 82% of BE patients completed the questionnaires. There was no difference in the scores of the eight subscales of the SF-36 between BE patients and those with GERD but without BE (p > 0.05). However, both groups scored below average on all subscales of the SF-36 compared to published US norms for an age- and gender-matched group. Using multivariable linear regression, the social functioning subscale of the SF-36 correlated with the presence of heartburn or acid regurgitation, severity of acid regurgitation, frequency of heartburn, frequency of acid regurgitation, and number of comorbidities. Similarly, the physical functioning subscale correlated with age, frequency of heartburn, and number of comorbidities. The bodily pain subscale correlated with the frequency of heartburn and number of comorbidities. The bodily pain subscale correlated with the frequency of heartburn and the severity of dysphagia, whereas the role emotional subscale correlated with the frequency of heartburn and the presence of dysphagia.

CONCLUSIONS

Although there were no differences in HRQL between BE and GERD patients, both groups scored below average on the subscales of the SF-36 compared to normal controls. GERD symptom frequency and severity were associated with bodily pain and with impaired social, emotional, and physical functioning, suggesting a profound impact on daily living.

Hospital credentialing and quality of care

The purpose of this study was to evaluate the impact of hospital credentialing standards on surgical outcomes for selected procedures. The study used hospital credentialing practices from a 1996 survey of North Carolina community hospitals, with surgical outcomes derived from a statewide database of inpatient surgical discharges in 1995. Hospital mortality, complications and elevated lengths of stay were used as outcome indicators in an analysis of 6 surgical procedures. Multivariate logit analysis was used to calculate the effects of hospital credentialing stringency and nine credentialing practices on outcomes, controlling for patient demographic characteristics, type of admission, severity of illness and hospital characteristics. Teaching hospitals adopted more stringent credentialing practices, with almost no difference between metropolitan and nonmetropolitan nonteaching facilities in their use of various credentialing policies. Surgical outcomes typically were not related to stringency of the hospital credentialing environment. Generally, the effect of specific practices was inconsistent (associated with improved outcomes for certain procedures and significantly worse outcomes for others) or counterintuitive (showing worse outcomes for selected surgical procedures where effects were statistically significant). More stringent hospital credentialing does not appear likely to improve patient outcomes.

A prospective trial of colchicine and methotrexate in the treatment of primary biliary cirrhosis

BACKGROUND & AIMS

The aim of this study was to determine if colchicine or methotrexate improves blood test results, symptoms, and/or liver histology in patients with primary biliary cirrhosis.

METHODS

Patients with histologically confirmed primary biliary cirrhosis whose serum alkaline phosphatase (ALP) levels were at least 2 times above normal and who were not yet candidates for liver transplantation received colchicine or methotrexate and were followed up for 2 years.

RESULTS

In patients receiving colchicine (n = 43), mean pruritus score decreased from 1.63 to 1.12 (P = 0.04), ALP level from 494 to 355 U/L (P < 0.0001), and alanine aminotransferase (ALT) level from 79 to 61 U/L (P < 0.0001). In patients receiving methotrexate (n = 42), pruritus score decreased from 1.25 to 0.44 (P = 0.0001), ALP from 478 to 235 U/L (P < 0.0001), and ALT from 96 to 61 U/L (P = 0.0001). Methotrexate but not colchicine significantly improved liver histology (P = 0.005) and serum immunoglobulin G levels (P = 0.0002). Methotrexate improved most blood test results more than colchicine. Serum bilirubin levels increased slightly with each drug, and albumin levels decreased slightly.

CONCLUSIONS

Both colchicine and methotrexate improved biochemical test results and symptoms in primary biliary cirrhosis, but the response to methotrexate was greater.

Economic analysis of endoscopic procedures

Economic analysis is becoming an important tool for the evaluation of new technologies. In this era of rapidly rising health care costs, we are required to demonstrate that our procedures are effective and cost-efficient. This article provides a glossary of terms for the evaluation and performance of an economic analysis and outlines the steps for performing an economic evaluation of an endoscopic procedure. The reader is provided with the skills to critically evaluate economic analyses of endoscopic technologies, and to determine their relevance to their practice.

A cost analysis of outpatient care for patients with Barrett's esophagus in a managed care setting

OBJECTIVES

Although Barrett's esophagus (BE) may be associated with severe gastroesophageal reflux disease (GERD), there are currently no studies that evaluate resource utilization in Barrett's patients. The aims of this study were 1) to determine the cost and number of endoscopies and clinic visits to the GI clinic for GERD or its complications in patients with BE; 2) to determine the pattern and cost of medication use in patients with BE; and 3) to compare medication use by patients with BE to that of patients with insulin-requiring diabetes mellitus (DM).

METHODS

Using the cost distribution report data and the pharmacy acquisition costs from the Durham VAMC, we calculated the monthly cost of endoscopies, clinic visits related to GERD, and medication use in 53 patients with BE between 1/1/94 and 1/1/97. We also calculated the average cost of medication use for 55 patients with insulin-requiring DM.

RESULTS

All patients with BE were male. Their median age was 64.0 yr (IQR 57-68). Of them, 92% were white; 23% had low-grade dysplasia (LGD). Patients with LGD were more likely to have more than three endoscopies in 3 yr than were those with no LGD (OR 6.3, 95% CI 1.11-35.67). There was no difference in clinic visits in the patients with and without dysplasia (OR 0.335, 95% CI 0.093-1.206). A total of 139 endoscopies and 172 clinic visits were observed. Outpatient care for patients with BE costs approximately $103/month or $1241/yr. Endoscopies and clinic visits accounted for 31.1% and 5.9% of the monthly medical cost, respectively. Medications accounted for 63% of the total cost of care. Prokinetic agents accounted for 0.8% of the total cost of medications, whereas histamine receptor antagonists (H2 blockers) and proton pump inhibitors (PPIs) accounted for 34.6% and 64.6%, respectively. Medication cost per month in patients with BE was approximately $65, similar to that of patients with insulin-requiring DM ($63).

CONCLUSIONS

Our conclusions were as follows: 1) Outpatient care for patients with BE costs approximately $1241/yr or ($103/month). 2) Medication use per month accounted for more than half of the total cost; PPIs accounted for 64.6% of total medication cost, suggesting that reflux was severe. 3) Consistent with current surveillance strategies, patients with LGD had more frequent endoscopy than patients with no dysplasia. 4) Medication cost per month in patients with BE is similar to that in patients with DM, another group with a chronic disorder. 5) Those who make health policy can use these results to compare the cost of care of patients with BE to the cost for those with other chronic medical disorders.

Barrett's esophagus: a new look at surveillance based on emerging estimates of cancer risk

OBJECTIVE

Surveillance of Barrett's patients is recommended, to detect dysplasia and early cancer. The reported risk for developing cancer varies substantially, however. Our previous analysis used an average cancer incidence of 1/75 patient-years (PY). Recent reports suggest that the risk may range from 1/251 to 1/208 PY in combined series of patients with long segment Barrett's esophagus (LSBE, >3 cm), and short segment Barrett's esophagus (SSBE), and up to 1% annually in patients with SSBE. Our goal was to consider these new estimates of cancer risk in a cost-utility analysis of surveillance of patients with Barrett's esophagus.

METHODS

Using our previously published model, we incorporated an average of the recent estimates of cancer risk (0.4% annually, 1/227 PY), and our primary data on quality of life after esophagectomy. We included actual variable (direct) costs and used a discount rate of 5%. From the perspective of an HMO, the model evaluates surveillance every 1-5 yr and no surveillance, with esophagectomy performed if high grade dysplasia is diagnosed, and calculates the incremental cost-utility ratios for each strategy.

RESULTS

The results suggest that, at our baseline, annual cancer risk surveillance every 5 yr is the only viable strategy. More frequent surveillance costs more and yields a lower life expectancy. The incremental cost-utility ratio for surveillance every 5 yr is $98,000/quality-adjusted life year (QALY) gained, comparable to the incremental cost-effectiveness ratios of accepted practices (heart transplantation and screening for tuberculosis in selected populations, $160,000/LY gained and $216,000/LY gained, respectively).

CONCLUSIONS

Surveillance of Barrett's patients should extend life, with incremental cost-utility ratios that compare favorably with some accepted medical practices. Policy makers can compare the cost of surveillance to that of other accepted practices to determine their willingness to fund surveillance.

Health-related quality of life: a primer for gastroenterologists

The evolution of health care has required physicians to evaluate more critically the impact of interventions on their patients' well-being. Prior clinical interventions focused primarily on biochemical and histological endpoints. These outcomes frequently were tenuously linked to patient benefit. Recently there has been a movement toward patient-oriented outcomes, including health-related quality of life (HRQL). The medical literature now frequently describes the effects of therapies on HRQL. Gastroenterologists need to understand the concepts behind HRQL and the use and utility of the various instruments employed to measure this outcome. The purpose of this article is: 1) to define the concept of health-related quality of life (HRQL); 2) to assess when measurement of HRQL can guide clinical decision-making; 3) to describe the desired properties of an HRQL instrument; and 4) to distinguish types of HRQL instruments. We discuss the varied definitions of HRQL and the clinical scenarios in which they are important. The psychometric properties of HRQL instruments, including validity, reliability, responsiveness, sensitivity, and coverage are defined and discussed. The types of instruments such as health profile, time trade-off, and standard gamble are contrasted. Finally, we compare generic and disease-specific instruments regarding their uses, strengths, and weaknesses. HRQL reflects patients' perceptions of disease and its impact on health status. It is becoming an increasingly important endpoint in therapeutic trials. By understanding its components and how it can meaningfully be measured, gastroenterologists may be better able to optimize the benefit patients receive from their medical interventions.

Prevalence of dyspepsia, heartburn, and peptic ulcer disease in veterans

OBJECTIVE

Medications used to treat gastrointestinal symptoms account for a substantial share of pharmacy expenses for veterans affairs medical centers. Prior studies have shown that the prevalence of peptic ulcer disease is higher in veterans than in nonveterans. Our aim was to determine the prevalence of upper gastrointestinal symptoms among patients seeking health care in the Department of Veterans Affairs outpatient clinics.

METHODS

A total of 1582 veterans completed a previously validated bowel symptom questionnaire in the following clinics: gastroenterology (n = 693), walk-in (n = 403), general medicine (n = 379), and women's health (n = 107).

RESULTS

Overall response was 78%. Dyspepsia was reported in 30%, 37%, 44%, and 53% of patients in general medicine, walk-in, women's health, and gastroenterology clinics, respectively. Heartburn, at least weekly, was reported in 21%, 21%, 28%, and 40% of patients in general medicine, walk-in, women's health, and gastroenterology clinics, respectively. Prior peptic ulcer disease (PUD) was reported in 29%, 26%, 22%, and 44% of patients in general medicine, walk-in, women's health, and gastroenterology clinics, respectively. Dyspepsia, heartburn, and PUD were significantly associated with increased physician visits and lower general health.

CONCLUSIONS

Dyspepsia and heartburn are common symptoms among veterans. Lifetime prevalence of PUD is high among veterans. Gastrointestinal symptoms have a significant impact on health care utilization and general health. These prevalence estimates provide a basis for studies of resource utilization and for cost-effectiveness analyses of the treatment of gastrointestinal disorders in the veteran population. Moreover, the high prevalence of symptoms helps to explain the high utilization of gastrointestinal medications.

Economic considerations for the hepatologist

This is an era of rapid change in health care systems and clinical practice. In the face of increasing national health care expenditures, physicians are confronted with an increased demand to justify practices and to show the value of their services. Hepatologists are being required to show that their practices are both effective and cost-effective. This has led to an expanding body of literature examining the cost-effectiveness of medical practices. To evaluate these economic analyses the reader must be familiar with the concepts used in economic analysis and have a clear understanding of both how these analyses are performed and how the results can be applied to clinical practice. The purpose of this article is to provide the reader with the essential concepts for evaluating economic analyses in the medical literature and to provide published criteria for performing and critiquing an economic analysis. The terms used in economic analysis are outlined and defined. The criteria for performing an economic analysis are listed. Examples are given to emphasize the key points.

Does this patient have Barrett's esophagus? The utility of predicting Barrett's esophagus at the index endoscopy

OBJECTIVES

Few studies have evaluated the ability of the endoscopist to predict the presence of Barrett's esophagus (BE) at index endoscopy. The goals of this study were to determine the operating characteristics of endoscopy in diagnosing BE, and to determine the clinical and endoscopic predictors of BE in suspected BE patients at the index endoscopy.

METHODS

From September 1993 to October 1997, endoscopic reports were examined to identify patients with suspected BE. All esophageal pathology reports during the same period were evaluated for the presence of specialized intestinal metaplasia.

RESULTS

During the study period, 4053 endoscopies were performed on 2393 patients. Eight percent of all procedures were performed for suspected or confirmed BE. Fifty-three patients were known to have BE and thus their reports were excluded from this analysis. Five hundred seventy of the remaining patients had esophageal biopsies performed, and were included in this analysis. Among these 570 patients, 146 were suspected to have BE on endoscopy, while 424 were not suspected to have BE at the time of endoscopy. There were no differences among the two groups in terms of gender, race, and dyspepsia as an indication for the endoscopy. However, suspected BE patients were slightly younger and were more likely to have heartburn, but were less likely to have dysphagia as an indication for the endoscopy. The sensitivity and specificity of the endoscopists' assessments were 82% (95% confidence interval [CI], 72-92) and 81% (95% CI, 78-84), respectively. The positive predictive value and the negative predictive value were 34% and 97%, respectively. The positive likelihood ratio was 4.32 (95% CI, 3.49-5.31) and the negative likelihood ratio was 0.22 (95% CI, 0.13-0.38). Univariate analysis showed that endoscopists diagnosed BE in those with long-segment BE (LSBE) more accurately than in those with short-segment BE (SSBE) (55% vs 25% p = 0.001; odds ratio [OR] = 3.63, 95% CI, 1.71-7.70). Barrett's esophagus was correctly diagnosed in 38.5% of white patients but in only 14.7% of black patients (p = 0.01; OR = 3.63, 95% CI, 1.31-10.13). Multivariable logistic regression identified only the length of the columnar-appearing segment (p = 0.002; OR = 3.33, 95% CI, 1.54-7.17) and race (p = 0.08; OR = 2.31, 95% CI, 0.88-6.03) to be associated with the presence of BE on biopsy.

CONCLUSIONS

Barrett's esophagus is frequently suspected at endoscopy; SSBE was more frequently suspected than LSBE, but was correctly diagnosed only 25% of the time, versus 55% for LSBE. Endoscopists diagnosed BE with a sensitivity of 82% and a specificity of 81%. However, the positive predictive value was only 34%, whereas the negative predictive value was 97%. The length of the columnar-appearing segment is the strongest predictor of BE at endoscopy. Alternative methods are needed to better identify BE patients endoscopically, especially those with SSBE.

Hospital credentialing for laparoscopic cholecystectomy: is stricter better?

OBJECTIVE

Hospital credentialing standards for laparoscopic cholecystectomy were established to improve surgical outcomes, but standards vary by hospital. We hypothesized that more stringent credentialing would result in better outcomes.

DESIGN

Univariate and multivariate logistic analyses were performed using a 1996 survey on hospital credentialing practices. Surgical-outcome data were obtained from statewide hospital discharge abstracts and hospital chart reviews. Multivariate logistic analysis was used to calculate the effects of hospital credentialing stringency and nine credentialing practices on operative and postoperative outcomes (including death), controlling for patient and hospital characteristics.

SETTING

Short-stay community hospitals performing laparoscopic cholecystectomy.

PATIENTS

Statewide hospital discharge data included 1995 inpatient discharges for laparoscopic cholecystectomy. Medical-records review included 843 laparoscopic cholecystectomy patients selected from 14 North Carolina hospitals with widely different credentialing practices.

RESULTS

Surgical complications from laparoscopic cholecystectomies appeared unrelated to stringency of the hospital credentialing environment. Important factors predicting complications included hospital volume and other hospital characteristics such as the number of registered nurses per patient day.

CONCLUSIONS

Given current levels of training, performance, and credentialing standards, tightening of credentialing practices may not improve patient outcomes for laparoscopic cholecystectomy.

Race, treatment, and survival among colorectal carcinoma patients in an equal-access medical system

BACKGROUND

The aim of this study was to assess the influence of race on the treatment and survival of patients with colorectal carcinoma.

METHODS

This retrospective cohort study included all white or black male veterans given a new diagnosis of colorectal carcinoma in 1989 at Veterans Affairs Medical Centers nationwide. After adjusting for patient demographics, comorbidity, distant metastases, and tumor location, the authors determined the likelihood of surgical resection, chemotherapy, radiation therapy, and death in each case.

RESULTS

Of the 3176 veterans identified, 569 (17.9%) were black. Bivariate analyses and logistic regression revealed no significant differences in the proportions of patients undergoing surgical resection (70% vs. 73%, odds ratio 0.92, 95% confidence interval 0.74-1.15), chemotherapy (23% vs. 23%, odds ratio 0.99, 95% confidence interval 0.78-1.24), or radiation therapy (17% vs. 16%, odds ratio 1.10, 95% confidence interval 0.85-1.43) for black versus white patients. Five-year relative survival rates were similar for black and white patients (42% vs. 39%, respectively; P=0.16), though the adjusted mortality risk ratio was modestly increased (risk ratio 1.13, 95% confidence interval 1.01-1.28).

CONCLUSIONS

Overall, race was not associated with the use of surgery, chemotherapy, or radiation therapy in the treatment of colorectal carcinoma among veterans seeking health care at Veterans Affairs Medical Centers. Although mortality from all causes was higher among black veterans with colorectal carcinoma, this finding may be attributed to underlying racial differences associated with survival. This study suggests that when there is equal access to care, there are no differences with regard to race.

Race, treatment, and survival among colorectal carcinoma patients in an equal-access medical system

BACKGROUND

The aim of this study was to assess the influence of race on the treatment and survival of patients with colorectal carcinoma.

METHODS

This retrospective cohort study included all white or black male veterans given a new diagnosis of colorectal carcinoma in 1989 at Veterans Affairs Medical Centers nationwide. After adjusting for patient demographics, comorbidity, distant metastases, and tumor location, the authors determined the likelihood of surgical resection, chemotherapy, radiation therapy, and death in each case.

RESULTS

Of the 3176 veterans identified, 569 (17.9%) were black. Bivariate analyses and logistic regression revealed no significant differences in the proportions of patients undergoing surgical resection (70% vs. 73%, odds ratio 0.92, 95% confidence interval 0.74-1.15), chemotherapy (23% vs. 23%, odds ratio 0.99, 95% confidence interval 0.78-1.24), or radiation therapy (17% vs. 16%, odds ratio 1.10, 95% confidence interval 0.85-1.43) for black versus white patients. Five-year relative survival rates were similar for black and white patients (42% vs. 39%, respectively; P=0.16), though the adjusted mortality risk ratio was modestly increased (risk ratio 1.13, 95% confidence interval 1.01-1.28).

CONCLUSIONS

Overall, race was not associated with the use of surgery, chemotherapy, or radiation therapy in the treatment of colorectal carcinoma among veterans seeking health care at Veterans Affairs Medical Centers. Although mortality from all causes was higher among black veterans with colorectal carcinoma, this finding may be attributed to underlying racial differences associated with survival. This study suggests that when there is equal access to care, there are no differences with regard to race.

Performing a cost-effectiveness analysis: surveillance of patients with ulcerative colitis

OBJECTIVE

To illustrate the principles of cost-effectiveness analysis, this third article in the "Primer on Economic Analysis for the Gastroenterologist" applies published criteria for appraising an economic analysis to a study of the cost-effectiveness of surveillance of patients with ulcerative colitis.

METHODS

We review and apply the 10 standard criteria for critical appraisal and evaluation of cost-effectiveness analyses.

SUMMARY

We outlined the development and critique of a decision analytic model that examines the cost-effectiveness of surveillance of patients with ulcerative colitis, and we compared the cost-effectiveness of surveillance of patients with ulcerative colitis to other well-accepted medical practices.

Effectiveness and patient satisfaction with nurse-directed treatment of Barrett's esophagus

OBJECTIVE

Using clinical practice guidelines, a registered nurse adjusted antireflux medications, evaluated esophageal biopsy reports, determined the interval between surveillance endoscopies, and provided education for patients with Barrett's esophagus. No previous reports have assessed the effectiveness or patient satisfaction associated with registered nurse-provided primary care. Because estimates of the incidence of dysplasia and adenocarcinoma vary widely, we also prospectively followed a cohort of patients with Barrett's esophagus.

METHODS

Charts were reviewed to determine the frequency of variation from guidelines, the annual incidence of dysplasia and adenocarcinoma, and frequency of reflux symptoms. Patients were mailed a questionnaire to assess satisfaction with their medical care and with the nurse.

RESULTS

Variation by the nurse from the guidelines on surveillance endoscopy (1.9%) and the treatment of reflux (1.3%) was rare. Most patients were very satisfied (score of 6 on 0-6-point Likert scale) with overall medical care (88%), and patient education (76%), and most patients did not think that increased physician involvement would improve their care (93%). Ninety-seven percent of patients had control of reflux symptoms. Two patients with long segment Barrett's esophagus (n = 67) developed high grade dysplasia over 323 patient-yr of follow-up (1 of 162 patient-yr for an annual incidence of 0.6%). No patients with short segment Barrett's esophagus (n = 56) developed high grade dysplasia or adenocarcinoma over 172 patient-years of follow-up.

CONCLUSION

The registered nurse in our clinical setting effectively administered clinical practice guidelines for the management of Barrett's esophagus without clinically significant morbidity or patient dissatisfaction. Before these results can be generalized to other settings, further studies will need to be performed.

Patient preferences and quality of life associated with colorectal cancer screening

OBJECTIVES

The goal of this study was to describe the attitudes of patients toward colorectal cancer screening, colon cancer, and colostomy.

METHODS

Using the time trade-off technique, we interviewed four groups of patients at a veterans' hospital: 1) 46 patients with colorectal cancer, 2) 24 patients undergoing screening sigmoidoscopy, 3) 114 subjects participating in a screening colonoscopy study, and 4) 62 patients who have never undergone endoscopic screening for colorectal cancer. Using this technique, we measured quality of life for six scenarios pertaining to screening for colorectal cancer, the patient's current health, colorectal cancer, and colostomy.

RESULTS

Unscreened patients were willing to give up significantly more time to avoid screening sigmoidoscopy and colonoscopy (median 91 days and 183 days, respectively) than were patients undergoing screening sigmoidoscopy (median 0 days and 7 days, respectively), screening colonoscopy (median 0 days and 0 days, respectively), or patients with colorectal cancer (median 0 days and 0 days, respectively). Cancer patients rated their current health state lower than volunteers for screening. Colon cancer and colostomy were rated similarly by all four groups. Substantial variation in patient attitudes was present in all groups.

CONCLUSIONS

Patients are generally very accepting of endoscopic screening for colorectal cancer. However, decisions regarding recommendations for colorectal cancer screening must take into account the variability in patient preferences. Effective alternative strategies should be available for those whose preferences do not comply with standard recommendations. The effect of patient education and physician recommendations on subjects' attitudes toward screening warrants further investigation.

Health-related quality of life after ileoanal pull-through evaluation and assessment of new health status measures

BACKGROUND & AIMS

Health-related quality of life (HRQL) after proctocolectomy is a critical parameter for management decisions in patients with chronic pancolitis. The aim of this study was to evaluate the HRQL of patients with ileoanal pull-through and to validate new, easy-to-administer HRQL measures.

METHODS

The Sickness Impact Profile (SIP), Short Form 36 (SF-36), Rating Form of Inflammatory Bowel Disease (IBD) Patient Concerns (RFIPC), and the time trade-off (TTO) were used to measure HRQL of pull-through patients. The SF-36 and the RFIPC were validated.

RESULTS

HRQL of patients with ileoanal pull-through was better than that of a national sample of patients with IBD (SIP and RFIPC) and similar to that of a normal population (SF-36). Physical and psychosocial subscales of the SF-36 correlated with the SIP, affirming the construct validity of the SF-36. The RFIPC results correlated with the SIP and SF-36 results, suggesting that it is also a valid health status measure for these patients. TTO results correlated with the physical subscales of the SIP and SF-36, reflecting the impact of physical health on this group.

CONCLUSIONS

HRQL of patients with ileoanal pull-through is excellent. The SF-36 and RFIPC are valid health status measures that can be used by clinicians and researchers in these patients.

Studying ulcerative colitis over the World Wide Web

OBJECTIVES

The Internet may provide a cost-effective means to collect outcomes data needed to improve the quality and efficiency of medical care. We explored the feasibility and methodology of a longitudinal outcomes study of Internet users who have ulcerative colitis (UC).

METHODS

We created an open-enrollment electronic survey of Internet users who have UC and recorded the number of respondents, their demographics, and their willingness to participate.

RESULTS

In a 2-month period, 582 users browsed the survey, 172 (30%) completed the questionnaire, and 162 (95%) reported willingness to enroll this study. Eighty-three percent were willing to release their medical records to verify their diagnosis. Most (> 70%) had the same E-mail address over 2 yr, suggesting that long-term follow-up could be performed electronically. In comparison with the male predominance of Internet users, respondents had gender distribution similar to that of patients who have UC. In comparison with the general population, respondents have higher education and higher household income.

CONCLUSIONS

The Internet community could serve as a resource for general population outcome studies. Selection bias due to limited availability and use of the networked computers may affect results. The Internet community, however, is expanding rapidly, so it should become more representative of the general population.

A reader's guide to economic analysis in the GI literature

To evaluate economic analyses and determine their value for clinical practice, the reader must have a clear understanding of how these analyses are performed and how the results can be applied to clinical practice. This second article in the "Primer on Economic Analysis for the Gastroenterologist" focuses on the critical assessment of economic evaluations in the gastrointestinal literature.

OBJECTIVES

The purpose of this article is (1) to review the criteria for the critical appraisal of an economic analysis, and (2) to apply these criteria to two recent articles that examine the cost-effectiveness of screening for hemochromatosis.

METHODS

The criteria for the critical appraisal of an economic analysis are outlined. To demonstrate the application of these criteria to the gastroenterology literature, they are used to evaluate two recent articles that examine the cost-effectiveness of screening for hemochromatosis.

SUMMARY/CONCLUSIONS

The reader of economic analyses in the gastroenterology literature is provided with a framework for the evaluation of such analyses and how they apply to gastroenterology. A systematic method for examining economic analyses and determining their value for the reader is illustrated.

Cost-effectiveness: definitions and use in the gastroenterology literature

In this era of rapid change in our health care system, we will be required to demonstrate that our practices and procedures in gastroenterology are both effective and cost-effective. In the face of rising national health care expenditures, the medical profession confronts an increased demand to justify practices and to demonstrate the value of its services. This has led to both an expansive literature examining the cost-effectiveness of practices and procedures and an alarming disparity in the definition and use of the term "cost-effectiveness." Many reports may be lacking appropriate documentation of costs and benefits, the critical components for the determination of cost-effectiveness.

OBJECTIVE

The purpose of this article was to define what is meant by a "cost-effective" intervention, with special reference to gastroenterology.

METHODS

The varied use of the term "cost-effective" in the gastroenterology literature is illustrated. Accepted definitions of the term are provided, and suggested uses are outlined. The value judgements that must be made in funding decisions are presented, and the parameters that may be used to determine the cost-effectiveness of a procedure or practice are discussed.

SUMMARY

Cost-effectiveness as it applies to GI medicine is defined, and appropriate and inappropriate uses of the term are illustrated. It is only through effective communication and precise definitions that we will be able to determine the cost-effectiveness of our practices in gastroenterology.

Prophylactic colectomy or surveillance for chronic ulcerative colitis? A decision analysis

BACKGROUND & AIMS

The treatment of patients with long-standing ulcerative colitis involving the entire colon is controversial. The aim of this study was to examine the effectiveness of surveillance colonoscopy or prophylactic colectomy on colon cancer mortality in patients with chronic ulcerative colitis.

METHODS

Using decision analysis, computer cohort simulation of patients with ulcerative colitis was performed to evaluate 17 strategies including no colonoscopic surveillance, surveillance at varying intervals, and prophylactic proctocolectomy with ileal pouch-anal anastomosis. The model examined which biopsy results (low-grade dysplasia, high-grade dysplasia, or cancer) should lead to proctocolectomy and ileal pouch-anal anastomosis. Published data on the incidence of cancer with ulcerative colitis, the sensitivity and specificity of colonoscopy with biopsy, the risks of colonoscopy and surgery, and the prognosis with colon cancer were used.

RESULTS

For a 30-year-old patient with pancolitis for 10 years, the model suggests that prophylactic colectomy would increase life expectancy by 2-10 months compared with surveillance and by 1.1-1.4 years compared with no surveillance. Surveillance would improve life expectancy by 7 months to 1.2 years compared with no surveillance. In sensitivity analysis, results were most affected by the cumulative incidence of cancer in patients with chronic ulcerative colitis.

CONCLUSIONS

Either surveillance or prophylactic colectomy should increase life expectancy in patients with ulcerative colitis.

Interstitial pneumonitis after low-dose methotrexate therapy in primary biliary cirrhosis

Interstitial pneumonitis is an uncommon complication of low-dose methotrexate therapy in patients with psoriasis but occurs in 3%-5% of patients with rheumatoid arthritis. We found a higher incidence of interstitial pneumonitis in patients with primary biliary cirrhosis (14%) and describe its clinical manifestations, treatment, and possible etiology. Blood tests, arterial blood gas determinations, chest radiographs, bronchoscopy, tear production, autoantibody tests, and serum immunoglobulin levels were obtained in six women who developed interstitial pneumonitis while receiving methotrexate in a double-blind prospective trial of methotrexate vs. colchicine in 87 patients with primary biliary cirrhosis. Six of 43 patients (14%) who received methotrexate compared with no patients receiving colchicine developed interstitial pneumonitis 19-61 weeks after starting treatment. The pneumonitis was characterized by dyspnea, hypoxemia, and bilateral lung infiltrates, all of which responded within 24 hours to the administration of intravenous glucocorticoids. There was no correlation between the pneumonitis and pre-existing lung disease, the severity of the primary biliary cirrhosis, the titer of antimitochondrial antibody, or other diseases associated with primary biliary cirrhosis. Patients with primary biliary cirrhosis receiving low-dose methotrexate (15 mg/wk) are more susceptible to interstitial pneumonitis than patients with psoriasis or rheumatoid arthritis. The pneumonitis appears to be a hypersensitivity reaction and responds rapidly to intravenous glucocorticoid therapy.

A guide for surveillance of patients with Barrett's esophagus

OBJECTIVE

Barrett's esophagus (columnar metaplasia of the distal esophagus due to chronic gastroesophageal reflux) affects nearly 700,000 people in the United States, and carries a risk of esophageal adenocarcinoma that is 30-125 times that of an age-matched population. Patients who develop high grade dysplasia are at greatest risk. Current recommendations are for endoscopic surveillance to detect dysplasia and to diagnose carcinoma while it is in an early and possibly treatable stage. In addition, some authorities recommend esophagectomy for high grade dysplasia, whereas others reserve esophagectomy only for those with cancer. There are no controlled trials demonstrating that surveillance increases life expectancy in patients with Barrett's esophagus. Furthermore, endoscopic surveillance of this large group with Barrett's esophagus may be costly, and associated with considerable morbidity. Therefore, our objective was to assess the effectiveness and cost-effectiveness of endoscopic surveillance in patients with Barrett's esophagus.

METHODS

Design--Decision analysis using a computer cohort simulation (Markov). We examined 12 strategies: (A) no endoscopic surveillance. Esophagectomy is performed only if cancer is detected by biopsy. (B) no surveillance. Esophagectomy is performed if high grade dysplasia is detected by biopsy: (C1-C5) surveillance at intervals from 1 to 5 yr, with esophagectomy if cancer is diagnosed, and (D1-D5) surveillance at intervals from 1 to 5 yr with esophagectomy if high grade dysplasia is diagnosed. We measured life expectancy, quality-adjusted life expectancy, and incremental cost-effectiveness ratios for each strategy. Data Sources--Medline Search and bibliographies of retrieved articles; expert opinion when published data were not available.

RESULTS AND CONCLUSIONS

Annual surveillance with esophagectomy for high grade dysplasia prevents cancer and is the preferred strategy, if only length of life (life expectancy) is considered. For those who consider both length and quality of life, endoscopy every 2-3 yr will provide the greatest quality-adjusted life expectancy. When costs are considered, endoscopy every 5 yr also increases life expectancy and has an incremental cost-effectiveness ratio similar to common medical practices. The cumulative incidence of cancer and the quality of life with an esophagectomy had the greatest impact on the decision for surveillance and the optimal surveillance strategy.

Evidence for diminished B12 absorption after gastric bypass: oral supplementation does not prevent low plasma B12 levels in bypass patients

Vitamin and mineral assays were performed on blood in 20 gastric bypass patients preoperatively and 6 and 12 months postoperatively. Values were compared with serial food records in nine patients. Postoperatively, all patients were prescribed a supplement containing the recommended dietary allowances (RDA) for vitamins and minerals. Weight, calorie and protein intake, and total serum protein decreased over the study interval (p less than 0.01). Dietary intakes of vitamins B1, B2, B6, folate, iron and zinc fell (p less than 0.01), but total intake (i.e., diet + supplement) did not decrease with the exception of iron. Blood indicators of these nutrients were normal preoperatively and did not decline. However, plasma vitamin B12 levels decreased from 385 pg/ml preoperatively to 234 pg/ml at 1 year (p = 0.0064), despite an increase in total vitamin B12 intake from 2.6 to 11.7 micrograms/day (p = 0.1173). Five patients (27.8%) had abnormally low plasma vitamin B12 levels at 1 year postoperatively; four were taking at least the RDA for vitamin B12 as supplements. Although oral supplementation containing the RDA for micronutrients can prevent abnormal blood indicators of most vitamins and minerals, it is insufficient to maintain normal plasma B12 levels in about 30% of gastric bypass patients.

Risk for colon adenomas in patients with rectosigmoid hyperplastic polyps

OBJECTIVE

To determine whether hyperplastic polyps found in the rectosigmoid area of the colon are associated with proximal adenomas, and to judge whether patients with distal hyperplastic polyps found during sigmoidoscopy might benefit from full colonoscopy.

DESIGN

Data on patients having colonoscopy collected prospectively according to a set protocol. The size and location of all polyps were noted, and all polyps were biopsied.

SETTING

Two university hospitals.

PATIENTS

One thousand eight hundred and thirty-six consecutive patients referred for colonoscopy between 31 December 1987 and 31 August 1989.

RESULTS

Of the 970 patients who met eligibility requirements, 274 (28.3%) had adenomas and 108 (11.1%) had hyperplastic polyps. The proportion of patients with distal hyperplastic polyps and proximal adenomas (31.9%) was similar to the proportion of those without distal hyperplastic polyps (23.0%) (crude odds ratio, 1.57; 95% CI, 0.77 to 3.06). After adjusting for age and sex, the results were unchanged (adjusted odds ratio, 1.53; CI, 0.82 to 2.88). Patients with distal adenomas, on the other hand, were three times more likely to have proximal adenomas than those without distal adenomas (adjusted odds ratio, 3.42; CI, 1.99 to 5.88).

CONCLUSIONS

Distal hyperplastic polyps are not strong predictors of risk for proximal adenomas. Based on the magnitude of the risk difference, we do not believe that finding a hyperplastic polyp during sigmoidoscopy justifies doing a full colonoscopy to search for proximal adenomas. Because rectosigmoid adenomas are associated with proximal adenomas, however, small polyps seen during sigmoidoscopy should be biopsied to determine their type. Colonoscopy should be reserved for patients who are proved to have adenomas.

Colon adenomas in patients with hyperplastic polyps

Although hyperplastic polyps are generally believed to have no malignant potential, recent work has suggested that they might be more common in patients with adenomas. We evaluated whether hyperplastic polyps could serve as a marker for patients who might benefit from colonoscopy. We retrospectively reviewed 1,588 consecutive colonoscopy reports and hospital charts on 1,407 different patients examined between May 1983 and August 1985: 242 patients had adenomas, and 94 had hyperplastic polyps. Of patients with hyperplastic polyps 93.6% had concomitant adenomas, as compared with 35.7% of those without, p less than 0.001. Adenomas proximal to the rectosigmoid were found in 61.7% of patients with hyperplastic polyps and in 25.3% of those without, p less than 0.001. Patients with hyperplastic polyps in the rectosigmoid had proximal adenomas more frequently (64.7%) than did those without rectosigmoid hyperplastic polyps (29.4%), p less than 0.001. We conclude that patients with hyperplastic polyps are more likely to have adenomas, and patients with rectosigmoid hyperplastic polyps are more likely to have proximal adenomas. Based on these preliminary data, we believe that the finding of hyperplastic polyps in the rectosigmoid might justify full colonoscopy and that this should be studied further.

Development of a scoring system to predict mortality from upper gastrointestinal bleeding

Despite the widespread application of endoscopy in acute upper gastrointestinal bleeding, there is little evidence of improved survival among those who undergo the procedure. To select high-risk patients who might benefit most from diagnostic and therapeutic endoscopy, the authors developed and validated a scoring system based on prognostic indicators of increased mortality. The scoring system was developed from the best clinical predictors of mortality, determined in a prospective study of consecutive bleeding patients. The model was then tested in a prospective validation phase at three hospitals. Three main factors in the model predict mortality: bleeding, including hematochezia, drop in hematocrit of 5%, short duration of bleeding, absence of melena, and hypotension; liver disease, manifested by prolonged prothrombin time and encephalopathy; and renal disease. Patients determined to be at high risk for death using the scoring system might be candidates for aggressive management and for therapeutic endoscopy.