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1.  CAG News Page 
PMCID: PMC3545618
4.  Clinical application of a single-operator direct visualization system improves the diagnostic and therapeutic yield of endoscopic retrograde cholangiopancreatography 
BACKGROUND:
Single-operator cholangioscopy enables direct diagnostic visualization and therapeutic intervention in the biliary tree. There is increasing evidence of its clinical utility in the assessment of biliary strictures and treatment of difficult stones.
OBJECTIVE:
To describe the first reported Canadian experience with managing biliary disease using single-operator cholangioscopy.
METHODS:
The present study was a retrospective analysis of data collected from all sequential patients undergoing single-operator cholangioscopy for assessment of biliary strictures and treatment of biliary stones. The main outcome measures were the ability to make an overall diagnosis of stricture (based on visual appearances and tissue histology), and to fragment and extract biliary stones.
RESULTS:
Thirty patients (17 women), mean age 66 years (range 41 to 89 years) underwent single-operator cholangioscopy. In biliary strictures (20 patients), overall accuracy for visual and tissue diagnosis was 84% and 81%, respectively. Successful electrohydraulic lithotripsy with stone clearance was achieved in 90% of the 10 patients who failed previous conventional therapy. The mean (± SD) procedure time was 61±21 min (range 20 min to 119 min). One patient developed mild postendoscopic retrograde cholangioscopy pancreatitis.
CONCLUSION:
The results of this experience reaffirms the clinical utility and safety of single-operator cholangioscopy for the management of biliary pathology. Further improvements can be achieved with increasing operator experience and refinements in optical technology.
PMCID: PMC3545621  PMID: 23378978
Biopsy; Cholangioscopy; Lithotripsy; SpyGlass; Stone; Stricture
5.  Long-term follow-up of patients with malignant pedunculated colon polyps after colonoscopic polypectomy 
BACKGROUND:
Previously published studies have suggested that patients with resected colon cancer have an increased risk for early metachronous colon cancer. Current screening guidelines recommend intense surveillance by colonoscopy for the initial five years after the initial colon cancer has been resected. Information regarding endoscopically removed malignant polyps is limited.
METHODS:
In the present study, 25 consecutive patients (14 male, 11 female) with malignant pedunculated colon polyps treated with snare cautery polypectomy were followed for more than one decade up to 20 years. Five patients required an additional resection to ensure that removal of the original cancer was complete. Annual colonoscopies were planned for five years. If an adenoma was detected in the fifth year, colonoscopy was performed annually until no adenomas were detected. Otherwise, colonoscopy was planned every three years after five years.
RESULTS:
In the present study, there was no mortality from colon cancer and no patient developed either recurrent colon cancer or an early metachronous colon cancer during the initial five-year period of surveillance. Two patients (one male, one female) ultimately developed late cecal cancers almost one decade after the original colon cancers were resected. One had an early stage cancer that was resected, while the other had an infiltrating mucinous carcinoma complicating a small tubulovillous adenoma with extension to a single lymph node. After surgical removal and adjuvant chemotherapy, no further neoplastic disease has been detected.
CONCLUSIONS:
Overall, patients with malignant pedunculated polyps do extremely well if appropriately managed at the time of the initial polypectomy. Short-term outcomes after removal of a malignant polyp(s) appear to be similar to those with a nonmalignant polyp. However, late metachronous colon cancer may still occur. Long-term follow-up should be considered in each patient, assuming reasonable life expectancy, because risk of additional adenomas and metachronous colon cancer persists even after the initial five years of currently recommended surveillance. Patients with resected malignant polyps may represent a special patient subgroup that requires surveillance for more extended periods than current guidelines have recommended.
PMCID: PMC3545622  PMID: 23378979
Adenoma; Colon cancer; Colonic adenocarcinoma; Colonoscopic polypectomy, Malignant colon polyps; Metachronous colon cancer
6.  Patient-identified quality indicators for colonoscopy services 
BACKGROUND:
Current quality improvement tools for endoscopy services, such as the Global Rating Scale (GRS), emphasize the need for patient-centred care. However, there are no studies that have investigated patient expectations and/or perceptions of quality indicators in endoscopy services.
OBJECTIVES:
To identify quality indicators for colonoscopy services from the patient perspective; to rate indicators of importance; to determine factors that influence indicator ratings; and to compare the identified indicators with those of the GRS.
METHODS:
A two-phase mixed methods study was undertaken in Montreal (Quebec), Calgary (Alberta) and Hamilton (Ontario) among patients ≥18 years of age who spoke and read English or French. In phase 1, focus group participants identified quality indicators that were then used to construct a survey questionnaire. In phase 2, survey questionnaires, which were completed immediately after colonoscopy, prompted respondents to rate the 20 focus group-derived indicators according to their level of importance (low, medium, high) and to list up to nine additional items. Multiple logistic regression analysis was used to determine the factors that influenced focus group-derived indicator ratings. Patient-identified indicators were compared with those used in the GRS to identify novel indicators.
RESULTS:
Three quality indicator themes were identified by 66 participants in 12 focus groups: communication, comfort and service environment. Of the 828 surveys distributed, 402 (48.6%) were returned and 65% of focus group-derived indicators were rated highly important by at least 55% of survey respondents. Indicator ratings differed according to age, sex, site and perceived colorectal cancer risk. Of the 29 patient-identified indicators, 17 (58.6%) were novel.
CONCLUSIONS:
Patients identified 17 novel quality indicators, suggesting that patients and health professionals differ in their perspectives with respect to quality in colonoscopy services.
PMCID: PMC3545623  PMID: 23378980
Colorectal cancer screening; Indicators; Quality
7.  The appropriateness of surveillance colonoscopy intervals after polypectomy 
BACKGROUND:
Adherence to surveillance colonoscopy guidelines is important to prevent colorectal cancer (CRC) and unnecessary workload.
OBJECTIVE:
To evaluate how well Canadian gastroenterologists adhere to colonoscopy surveillance guidelines after adenoma removal or treatment for CRC.
METHODS:
Patients with a history of adenomas or CRC who had surveillance performed between October 2008 and October 2010 were retrospectively included. Time intervals between index colonoscopy and surveillance were compared with the 2008 guideline recommendations of the American Gastroenterological Association and regarded as appropriate when the surveillance interval was within six months of the recommended time interval.
RESULTS:
A total of 265 patients were included (52% men; mean age 58 years). Among patients with a normal index colonoscopy (n=110), 42% received surveillance on time, 38% too early (median difference = 1.2 years too early) and 20% too late (median difference = 1.0 year too late). Among patients with nonadvanced adenomas at index (n=96), 25% underwent surveillance on time, 61% too early (median difference = 1.85) and 14% too late (median difference = 1.1). Among patients with advanced neoplasia at index (n=59), 29% underwent surveillance on time, 34% too early (median difference = 1.86) and 37% later than recommended (median difference = 1.61). No significant difference in adenoma detection rates was observed when too early surveillance versus appropriate surveillance (34% versus 33%; P=0.92) and too late surveillance versus appropriate surveillance (21% versus 33%; P=0.11) were compared.
CONCLUSION:
Only a minority of surveillance colonoscopies were performed according to guideline recommendations. Deviation from the guidelines did not improve the adenoma detection rate. Interventions aimed at improving adherence to surveillance guidelines are needed.
PMCID: PMC3545624  PMID: 23378981
Appropriateness; Colonoscopy; Surveillance; Yield
8.  The utility of thiopurine methyltransferase enzyme testing in inflammatory bowel disease 
OBJECTIVE:
To assess the levels of red blood cell thiopurine methyltransferase (TPMT) in subjects with inflammatory bowel disease (IBD) and to determine how these levels impacted thiopurine dosing and leukopenia over the first six months of therapy.
METHODS:
A retrospective chart review was performed on all adult IBD patients (n=423, 88.2% Caucasian) who had TPMT levels measured by 11 participating gastroenterologists in Manitoba between 2008 and 2010. In addition to descriptive data, white blood cell count, dose and reason for discontinuation were analyzed for the first six months of therapy. Patients receiving ≥2.0 mg/kg of azathioprine (AZA) or ≥1.0 mg/kg of 6-mercapatopurine were considered to be ‘substantially’ dosed.
RESULTS:
Of the 423 patients, 8.3% had intermediate levels and 93.4% had normal levels of TPMT. Only one subject had a low level. A total of 216 patients had sufficient data to be included for full analysis. Patients with intermediate TPMT levels were generally started at lower doses of thiopurine than patients with normal TPMT levels (mean [± SD] 1.0±0.6 mg/kg versus 1.8±0.5 mg/kg). Of the subjects with normal TPMT levels, only 37.8% were dosed with ≥2.0 mg/kg of AZA. Each month, approximately 5% of subjects were leukopenic. These subjects received a mean overall AZA dose of 1.9±0.3 mg/kg and had a mean white blood cell count of 3.8±0.4×109/L.
CONCLUSIONS:
Normal TPMT levels did not prevent the development of leukopenia, although life-threatening leukopenia was rare. Physicians are not using TPMT levels to substantially dose thiopurines at the outset, which may limit the speed at which adequate doses are reached to facilitate remission.
PMCID: PMC3545625  PMID: 23378982
Crohn disease; Leukopenia; Ulcerative colitis; Thiopurines; Thiopurine methyltransferase
9.  Predictors of recurrent ingestion of gastrointestinal foreign bodies 
BACKGROUND:
Gastrointestinal foreign bodies are commonly encountered; however, little knowledge exists as to the causes of foreign body ingestions and why they occur repeatedly in some patients.
OBJECTIVE:
To identify and define patients at high risk for recurrent foreign body ingestion.
METHODS:
A retrospective chart review of foreign body ingestion was conducted at a tertiary care medical centre over an 11-year period. Variables analyzed included age, sex, incarceration status, Diagnostic and Statistical Manual of Mental Disorders-IV diagnosis, success of endoscopy, type of sedation used, method of extraction, complications, presence of gastrointestinal pathology, and incidence of recurrent food impaction or foreign body.
RESULTS:
A total of 159 patients with a foreign body ingestion were identified. One hundred fourteen (77%) experienced a single episode of ingestion and 45 (23%) experienced multiple ingestions. Of the patients with multiple ingestions, 27 (60%) had recurrent food impactions while 18 (40%) ingested foreign objects. In the recurrent ingestor group, a psychiatric disorder had been diagnosed in 16 patients (35.6%) and there were 13 incarcerated individuals (28.9%). The average number of recurrences was 2.6 per patient (117 total recurrences). Individuals with a psychiatric disorder experienced 3.9 recurrences per patient, while prisoners averaged 4.1 recurrences per patient. The combination of a psychiatric disorder and being incarcerated was associated with the highest recurrence rate (4.33 per patient). Multivariable logistic regression revealed that male sex (OR 2.9; P=0.022), being incarcerated (OR 3.0; P=0.024) and the presence of a psychiatric disorder (OR 2.5; P=0.03) were risk factors for recurrent ingestion.
CONCLUSION:
Risk factors for recurrent ingestion of foreign bodies were male sex, being incarcerated and the presence of a psychiatric disorder.
PMCID: PMC3545626  PMID: 23378983
Foreign body; Recurrent esophageal impaction
10.  Hedgehog signalling is downregulated in celiac disease 
BACKGROUND:
Celiac disease (CD) is a common autoimmune disorder of the small intestine that occurs in genetically predisposed individuals. Animal studies have suggested that the hedgehog (Hh) signalling pathway is involved in gut inflammation, injury and repair.
OBJECTIVE:
To examine the expression of components of the Hh signalling pathway in CD.
METHODS:
Children undergoing gastroscopy investigation for CD at Monash University (Victoria, Australia), and other children undergoing gastroscopy in whom small bowel pathology was not expected (ie, controls), were included in the present study. One histopathologist, who was blinded to the biopsy data, analyzed the biopsies and a diagnosis of CD was made according to standard Marsh criteria. From these samples, RNA was extracted and complementary DNA was synthesized using reverse transcription polymerase chain reaction. The levels of Hh ligand Sonic hh, Indian hh, protein patched homologue 1 (PTCH 1) and bone morphogenetic protein 4 (BMP4) messenger RNA were quantified by real-time polymerase chain reaction. Relative expression quantification was performed using the ΔΔCt method.
RESULTS:
Duodenal biopsies were collected from 37 children. There were 20 CD specimens and 17 normal controls. The relative expression of Sonic hh from CD patients was 58% lower than that of the controls; similarly, Indian hh expression was decreased in children with CD by 44%. Compared with controls, the expression of Hh receptor PTCH 1 decreased by 71% and the expression of the Hh target gene BMP4 by 42%.
CONCLUSIONS:
The expression of the Hh signalling pathway genes was consistently downregulated in untreated CD children. These results suggest that the Hh signalling pathway plays a role in the mucosal lesions encountered in CD.
PMCID: PMC3545627  PMID: 23378984
BMP4; Celiac disease; Duodenum; Hedgehog signalling; PTCH1
11.  Epidemiology and treatment of hepatitis C genotypes 5 and 6 
Chronic hepatitis C infection is a major global health problem. The WHO estimates the number of infected people worldwide to be approximately 170 million. The estimated number of hepatitis C virus (HCV)-infected people in Canada is approximately 250,000, with approximately 5000 Canadians newly infected each year. Based on the identification of genomic differences, HCV has been classified into six genotypes; genotype may influence the outcome of antiviral therapy. HCV genotypes 1, 2 and 3 are widely distributed throughout the world and have been the focus of the majority of epidemiological, natural course and treatment studies. Although HCV genotypes 5 and 6 are prevalent in certain geographical areas, they are studied less extensively. HCV genotypes 5 and 6 are uncommon in Canada and account for less than 5% of HCV-infected Canadians. However, immigration and travel can alter the epidemiology of these uncommon genotypes. The present article reviews and summarizes the available data regarding the epidemiology and treatment of HCV genotypes 5 and 6. Genotype 5 is endemic in the northern part of South Africa while genotype 6 is reported primarily in Asia. Available data show that 48 weeks of treatment with a combination of pegylated interferon and ribavirin lead to a higher sustained virological response compared with HCV genotypes 1 and 4. None of the approved direct-acting antiviral agents is currently recommended for the treatment of HCV genotypes 5 or 6.
PMCID: PMC3545628  PMID: 23378985
Chronic; Hepatitis C; Genotype
12.  Management of chronic hepatitis B: Canadian Association for the Study of the Liver consensus guidelines 
Chronic hepatitis B (CHB) is a dynamic disease that is influenced by host and virological factors. The management of CHB has become more complex with the increasing use of long-term oral nucleos/tide analogue antiviral therapies and the availability of novel diagnostic assays. Furthermore, there is often a lack of robust data to guide optimal management such as the selection of therapy, duration of treatment, potential antiviral side effects and the treatment of special populations. In November 2011, the Canadian Liver Foundation and the Canadian Association for the Study of the Liver convened a consensus conference to review the literature and analyze published data, including other international expert guidelines on CHB management. The proceedings of the consensus conference are summarized and provide updated clinical practice guidelines to assist Canadian health care providers in the prevention, diagnosis, assessment and treatment of CHB.
PMCID: PMC3551569  PMID: 23248795
Antiviral therapy; Canadian; Chronic hepatitis B; Hepatitis B virus infection; Management
13.  Epigenetics and the developmental origins of inflammatory bowel diseases 
The gut microbiota, the intestinal mucosa and the host immune system are among the large biological networks involved in the development of inflammatory bowel disease (IBD), which includes Crohn disease (CD) and ulcerative colitis (UC). Host genetics and environmental factors can significantly modulate the interactive relationships among these biological systems and influence predilection toward IBD. High monozygotic twin discordance rates and the rapid rise in the prevalence of IBD indicate that environmental influences may be as important or even more important in their pathogenesis than genetic susceptibility. However, the nature and timing of environmental factors critical for inducing IBD remain largely unknown. The molecular mechanisms and the key biological component(s) that may be affected by such factors are also in question. Epigenetic changes, such as DNA methylation (the methylation of cytosines followed by a guanine in CpG dinucleotides) can be modified by environmental influences during finite developmental periods and have been implicated in the pathogenesis of IBD. Mucosal DNA methylation can also react to changes in the commensal microbiota, underscoring the intercalating relationships among the large biological systems involved in gastrointestinal disorders. Therefore, transient environmental influences during specific periods of development may induce critical change(s) in an isolated or concomitant fashion within the intestinal biomic networks and lead to increased susceptibility to IBD. The present review focuses on the emerging paradigm shift considering IBD to originate from critical environmental effects during pre- and postnatal development.
PMCID: PMC3551568  PMID: 23248794
Diet; DNA methylation; Epigenetics; Inflammatory bowel disease; Microbiome
14.  Venous thromboembolism in cirrhosis: A review of the literature 
Although hemorrhage has traditionally been regarded as the most significant hemostatic complication of liver disease, there is increasing recognition that hypercoagulability is a prominent aspect of cirrhosis. Identifying markers of coagulability and monitoring anticoagulation therapy in the setting of cirrhosis is problematic. The bleeding risk of venous thromboembolism (VTE) prophylaxis and treatment in patients with chronic liver disease is unclear and there are currently no recommendations to guide practice in this regard. In the present report, the mechanism of coagulation disturbance in chronic liver disease is reviewed with an examination of the evidence for an increased VTE risk in cirrhosis. Finally, the available evidence is assessed for prophylaxis and therapy of VTE in chronic liver disease, and the role it may play in decreasing clinical decompensation and improving survival.
PMCID: PMC3551567  PMID: 23248793
Cirrhosis; Venous thromboembolism
15.  Report on the Expert Forum on Using Information Technology to Facilitate Uptake and Impact of Colorectal Cancer Screening Guidelines 
The present report summarizes the proceedings of the pan-Canadian Expert Forum on Using Information Technology to Facilitate Uptake and Impact of Colorectal Cancer Screening Guidelines, which was held in Montreal, Quebec, November 18 to 19, 2011. The meeting assembled a multidisciplinary group of family physicians, gastroenterologists, nurses, patients, foundation representatives, screening program administrators and researchers to discuss the development of a mechanism or strategy that would permit the collection of comparable data by all colorectal cancer (CRC) screening programs, which would not only support the needs of each program but also provide a national perspective. The overarching theme of the meeting was ‘designing a national approach to computerized electronic data collection and dissemination for CRC screening that would improve knowledge transfer across the continuum of preventive health care’. The forum encouraged presentations on clinical, research and technical topics. The meeting fostered valuable cross-disciplinary communication and delivered the message that it is essential to develop a national health informatics approach for CRC screening data collection and dissemination to support provincial CRC screening programs.
PMCID: PMC3551566  PMID: 23248792
Colorectal cancer; Information technology; National registry; Report; Screening
16.  Wait times for diagnostic colonoscopy among outpatients with colorectal cancer: A comparison with Canadian Association of Gastroenterology targets 
BACKGROUND:
Timely access to colonoscopy is a nationally recognized issue in Canada, with previous studies documenting significant wait times for a variety of indications. However, specific wait times for colonoscopy among patients diagnosed with colorectal cancer remain unknown.
METHODS:
A review of all outpatient cases of colorectal cancer diagnosed at colonoscopy in London, Ontario, in 2010 was performed. Wait times from the date of referral to colonoscopy were reviewed and compared with maximal wait times established by the Canadian Association of Gastroenterology (CAG) stratified according to indication. Cancer stage at the time of diagnosis was compared with colonoscopy wait times.
RESULTS:
A total of 106 colorectal cancer patients meeting the inclusion and exclusion criteria were included in the study. Forty-six per cent of patients waited longer than CAG targets, with a mean (± SD) wait time of 79±101 days. Higher cancer stage was associated with shorter wait time, likely as a result of triaging.
CONCLUSION:
Long wait times for diagnostic colonoscopy among patients with colorectal cancer remain an issue, with a significant proportion of cases not meeting maximal CAG wait time targets.
PMCID: PMC3551564  PMID: 23248790
Colonoscopy; Colorectal cancer; Wait times
17.  Etiology of small bowel thickening on computed tomography 
BACKGROUND:
Abdominal pain is often evaluated using imaging, most often with computed tomography (CT). While CT is sensitive and specific for certain diagnoses, small bowel thickening is a nonspecific finding on CT with a broad differential diagnosis including infection, inflammation, ischemia and neoplasm.
METHOD:
A review of medical records of patients who underwent CT scans of the abdomen and pelvis over a one-year period and exhibited small bowel thickening were retrospectively evaluated to determine the final diagnosis.
RESULTS:
The etiologies of small bowel thickening on CT were as follows: infection (113 of 446 [25.34%]); reactive inflammation (69 of 446 [15.47%]); primary inflammation (62 of 446 [13.90%]); small bowel obstruction (38 of 446 [8.52%]); iatrogenic (33 of 446 [7.40%]); neoplastic (32 of 446 [7.17%]); ascites (30 of 446 [6.73%]); unknown (28 of 446 [6.28%]); ischemic (24 of 446 [5.38%]); and miscellaneous (17 of 446 [3.81%]).
CONCLUSION:
Infectious and inflammatory (primary or reactive) conditions were the most common cause of small bowel thickening in the present series; these data can be used to formulate a more specific differential diagnosis.
PMCID: PMC3551565  PMID: 23248791
Inflammatory; Ischemic; Neoplastic; Small bowel; Thickening
18.  Digestive symptoms in older adults: Prevalence and associations with institutionalization and mortality 
BACKGROUND:
Digestive symptoms are common in adults. However, little is known about their prevalence in older adults and the association of digestive symptoms with institutionalization and mortality in community-dwelling older adults.
OBJECTIVE:
To determine the prevalence of digestive symptoms among older adults in Canada and whether they are associated with increased risk of institutionalization and mortality, independent of the effect of potential confounders.
METHODS:
The present study was a secondary analysis of data collected from community-dwelling participants 65 years of age and older in the Canadian Study of Health and Aging. Measures incuded age, sex, presence of digestive symptoms, cognition, impairment in activities of daily living (ADL) and self-reported health. Outcome measures included death or institutionalization over the 10 years of follow-up.
RESULTS:
Digestive symptoms were found in 2288 (25.6%) of the 8949 subjects. Those with digestive symptoms were older, with a mean difference in age of six months (P=0.007). Digestive symptoms were more common among women (28.4%) than men (20.3%), among individuals with poor self-reported health and those with an increased number of impairments in their ADLs (P<0.001). The presence of digestive symptoms was associated with higher mortality (HR 1.15 [95% CI 1.05 to 1.25] adjusted for age, sex, cognitive function and ADL impairment); however, this association was not statistically significant after adjusting for self-reported health.
CONCLUSION:
Although digestive symptoms were associated with increased mortality independent of age and sex, cognition and function, this association was largely explained by poor self-assessed health. Digestive symptoms were not associated with institutionalization
PMCID: PMC3551561  PMID: 23248787
Activities of daily living; Aged; Digestive symptoms; Epidemiology; Institutionalization; Mortality
19.  A cohort study for the derivation and validation of a clinical prediction scale for hospital-onset Clostridium difficile infection 
OBJECTIVE:
To develop and validate a clinical prediction scale for hospital-onset Clostridium difficile infection (CDI).
METHODS:
A community-based, 360-bed hospital located in the suburbs of a metropolitan area in the United States served as the setting for the present retrospective cohort study. The cohort consisted of patients admitted to the adult medical service over a six-year period from October 2005 to September 2011. The cohort was divided into derivation (October 2005 to September 2009) and validation (October 2009 to September 2011) groups. The primary outcome measure was hospital-onset CDIs identified as stool positive for C difficile after 48 h of hospital admission ordered for new-onset unformed stool by the treating physician.
RESULTS:
In the derivation phase, 35,588 patients were admitted to the medical service and 21,541 stayed in hospital beyond 48 h. A total of 266 cases of CDI were identified, 121 of which were hospital onset. The developed clinical prediction scale included the onset of unformed stool (5 points), length of hospital stay beyond seven days (4 points), age >65 years (3 points), long-term care facility residence (2 points), high-risk antibiotic use (1 point) and hypoalbuminemia (1 point). The scale had an area under the receiver operating curve (AUC) of 0.93 (95% CI 0.82 to 0.94) in predicting hospital-onset CDI, with a sensitivity of 0.94 (95% CI 0.88 to 0.97) and a specificity of 0.80 (95% CI 0.79 to 0.80) at a cut-off score of 9 on the scale. During the validation phase, 16,477 patients were admitted, of whom 10,793 stayed beyond 48 h and 58 acquired CDI during hospitalization. The predictive performance of the score was maintained in the validation cohort (AUC 0.95 [95% CI 0.93 to 0.96]) and the goodness-to-fit model demonstrated good calibration.
CONCLUSION:
The authors developed and validated a simple clinical prediction scale for hospital-onset CDI. This score can be used for periodical evaluation of hospitalized patients for early initiation of contact precautions and empirical treatment once it is validated externally in a prospective manner.
PMCID: PMC3551562  PMID: 23248788
Clinical prediction scale; Clostridium difficile infection
20.  Qualitative study of physician perspectives on classifying screening and nonscreening colonoscopy using administrative health data: Adding practice does not make perfect 
BACKGROUND:
Previously developed screening colonoscopy algorithms based on diagnostic and endoscopy procedural variables have not been sufficiently accurate for use in epidemiological and health services research.
OBJECTIVE:
To increase understanding of the administrative health database variables that could help to discern screening and nonscreening colonoscopy.
METHODS:
A qualitative study using physician focus groups was conducted in Montreal (Quebec), Calgary (Alberta) and Toronto (Ontario). Specialty-specific focus group sessions were held among family physicians and gastroenterologists – the physicians responsible for referring patients to and performing screening colonoscopy, respectively. Interview guides were developed to better understand physician clinical and billing practices. Discussions were audiotaped, transcribed verbatim and analyzed using the constant comparative approach.
RESULTS:
Forty family physicians and seven gastroenterologists participated in five focus group sessions. Patient variables included demographics (age) and medical history (colorectal cancer risk factors/symptoms, medication for colorectal cancer risk factors/symptoms, gastrointestinal disorders, severe disease). Clinical practice variables included timing of the colonoscopy (evenings, weekends, holidays, during hospitalization; same-day endoscopist consultation and colonoscopy), use of services (hospitalization, annual examination, transfer from other facility) and procedure use patterns (large bowel or other medical/surgical procedure before and subsequent to colonoscopy). However, wide variability in clinical and billing practices will likely preclude the development of a reasonably accurate screening colonoscopy algorithm. Physicians suggested adding a screening colonoscopy code to the administrative health data.
CONCLUSIONS:
Failure to acknowledge the limitations of the provincial administrative health databases to identify screening colonoscopy may lead to incorrect conclusions and the establishment of inappropriate health care policies.
PMCID: PMC3551563  PMID: 23248789
Colonoscopy indication; Colorectal cancer screening; Physician perspective; Qualitative
21.  Trends in time to diagnosis of colon cancer and impact on clinical outcomes 
BACKGROUND:
There has been a rapid increase in screening for colorectal cancer (CRC) over the past several years in North America. This could paradoxically lead to worsening outcomes if the system is not adapted to deal with the increased demand. For example, this could create increased wait times for endoscopy and delayed time to CRC diagnosis, which could worsen clinical outcomes such as stage at diagnosis and/or survival. No previous Canadian study has evaluated the association between time to CRC diagnosis and clinical outcomes.
METHODS:
The present historical cohort study used Manitoba’s population-based cancer registry and Manitoba Health administrative databases. The effect of time to diagnosis on patient survival was evaluated using Cox regression analysis with adjustment for stage at diagnosis, grade of CRC, age, sex, socioeconomic status, comorbidity index score and year of CRC diagnosis. The association between time to diagnosis and CRC stage at diagnosis was evaluated using multivariate logistic regression analysis.
RESULTS:
The median time to CRC diagnosis increased significantly from 72 days (95% CI 61 days to 83 days) in 2004 to 105 days (95% CI 64 days to 129 days) in the first three months of 2009 (P=0.04). There was no significant association between time to diagnosis and survival. Individuals with the longest time to diagnosis were less likely to have stage III/IV CRC at diagnosis (quartile 4 versus quartile 1: OR 0.50 [95% CI 0.33 to 0.75).
CONCLUSION:
Time to CRC diagnosis is continuing to increase in Manitoba. Although the present study did not detect a significant negative clinical effect of increasing time to diagnosis, additional studies are required.
PMCID: PMC3551560  PMID: 23248786
Colon cancer; Stage at diagnosis; Survival; Time trends
23.  A survey of the practice of after-hours and emergency endoscopy in Canada 
OBJECTIVE:
To determine staffing and practice patterns for after-hours endoscopy service in Canada
METHODS:
A link to a web-based survey was sent by e-mail to all clinical members of the Canadian Association of Gastroenterology in February 2011. A priori, it was planned to compare variations in practice among gastroenterologists (GIs) performing endoscopy in different regions of Canada, between pediatric and adult GIs, and between university and community hospitals.
RESULTS:
Of 422 potential respondents, 168 (40%) responded. Of the 139 adult GIs, 61% performed after-hours endoscopy in the endoscopy suite where daytime procedures were performed, 62% had a trained endoscopy nurse available for all procedures, 38% had access to propofol sedation, 12% reprocessed the endoscopes themselves or with the help of a resident, 4% had out-of-hospital patients come directly to their endoscopy suite and 53% were highly satisfied. The adult endoscopists practising at community hospitals were more likely to have an anesthetist attend the procedure. Regional differences were noted, with more involvement of anesthetists (13%) and availability of propofol (50%) in Ontario, more frequent reprocessing of endoscopes in the central reprocessing units in British Columbia (78%) and almost universal availability of a trained endoscopy nurse (96%) with concomitant higher endoscopist satisfaction (84% highly satisfied) in Alberta.
CONCLUSIONS:
More than one-third of surveyed endoscopists across the country do not have a trained endoscopy nurse to assist in after-hours endoscopy – the time period when urgent patients often present and typically require therapeutic endoscopic interventions. There are significant regional differences in the practice of after-hours endoscopy in Canada.
PMCID: PMC3551559  PMID: 23248785
Emergency care; Endoscopy; Staffing; Standards
24.  CAG News Page 
PMCID: PMC3551557

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