Diverticulosis and the Risk of Interval Colorectal Cancer

Background

Diverticulosis, a prevalent condition at screening colonoscopy, has been associated with colorectal cancers that develop after a clearing colonoscopy, or interval cancers.

Aims

To quantify the overall risk of diverticulosis in the development of interval cancers and examine this association in relevant subgroups.

Methods

Using a linked database containing SEER tumor registry data and Medicare claims, we identified patients aged ≥69 years with colorectal cancer who underwent colonoscopy within 6 months of diagnosis. Patients with an additional colonoscopy from 36 to 6 months prior to cancer diagnosis were characterized as having interval cancers. We compared characteristics of patients with interval cancers and detected cancers according to a diagnosis of diverticulosis not associated with a colonoscopy procedure from 1991 through the date of the most recent colonoscopy in both univariate and multivariate models.

Results

A previous diagnosis of diverticulosis was documented in 14,452 (26.9 %) patients with detected cancers compared to 2,905 (69.3 %) patients with interval cancers (p < 0.001); these results were consistent in multivariable analysis. Moreover, the association was found as well in the proximal colon (OR 2.88, 95 % CI 2.66, 3.12), distal colon (OR 3.56, 95 % CI 3.09, 4.11), and rectum (OR 4.07, 95 % CI 3.34, 4.95). The vast majority of diverticulosis diagnoses were without complications such as hemorrhage or diverticulitis.

Conclusions

Diverticulosis was strongly associated with interval colorectal cancers in all segments of the colon. Given its known predominance in the left colon, the findings argue against impaired visualization of lesions at colonoscopy as the only pathogenic factor.     

Duodenal Adenomas Coincide with Colorectal Neoplasia

Background and Aim

Small case series have alluded to an association between sporadic duodenal adenomas and colorectal neoplasia. The strength of the association remains uncertain. This case–control study was designed to test this association in a large national pathology database.

Methods

This study, performed at Miraca Life Sciences, a specialized pathology laboratory that receives gastrointestinal biopsy specimens from outpatient centers throughout the US, included all subjects who underwent a bidirectional endoscopy with biopsy results from both procedures between January 2008 and December 2011. The association between duodenal and colonic neoplasms was investigated using odds ratios (OR) and their 95 % confidence intervals (CIs) derived from univariate and multivariate analyses.

Results

There were 203,277 patients who underwent bidirectional procedures within the study period (mean age 58 years, 58 % females). Duodenal adenomas were present in 537 patients (median age 65 years, 51 % females; OR for male sex 1.34, 95 % CI 1.13–1.59). Hyperplastic colon polyps were present in 30,205 and colon adenomas in 85,801 patients. Hyperplastic polyps were more common in patients with duodenal adenomas (1.45, 1.07–1.95). Patients with duodenal adenomas also had a significantly greater prevalence of all types of colonic adenomas (2.65, 2.16–3.25), particularly of advanced adenomas (4.30, 3.24–5.70) and colorectal cancer (3.13, 1.38–7.12). Duodenal adenomas were associated with an equally increased risk for left and right colon adenomas.

Conclusions

Patients with duodenal adenomas harbor an increased risk for any type of colonic neoplasm. This association may provide new insights into the general mechanisms underlying mucosal proliferation in the gastrointestinal tract.     

Low frequency of polyps in colonic regions with diverticulosis

Purpose

Conflicting evidence exists regarding any association between diverticulosis and adenomatous polyps. We evaluated the prevalence of polyps and cancer in colonic regions containing diverticula.

Methods

Six hundred consecutive colonoscopy reports from a single endoscopist were reviewed to determine prevalence and location of diverticulosis and polyps. Additionally, pathology reports of 88 colon cancer resection specimens were reviewed for the presence of diverticulosis, and compared with expected prevalence of diverticulosis in that colonic region based on the collected colonoscopy data.

Results

Overall, rates of detected polyps were comparable between patients with and without diverticulosis. However, analyzing the data by colonic segment containing diverticulosis, the prevalence of adenomatous polyps was reduced in regions of diverticulosis compared to the same colonic segment unaffected by diverticulosis (7 vs. 17% for rectosigmoid (p = 0.005); 5 vs. 18% for descending (p < 0.0001); and 17 vs. 27% for ascending colon (p = 0.0495)). Among colon cancer resection specimens, the prevalence of diverticulosis was significantly reduced in the rectosigmoid and ascending colon, compared with expected rates of diverticulosis in those regions. (13 vs. 42% in rectosigmoid (p = 0.0006); 3 vs. 17% in ascending colon (p = 0.043)).

Conclusion

Despite similar overall frequency of polyps in patients with and without diverticulosis, polyps were significantly less likely in the colonic segment affected by diverticulosis. Additionally, the frequency of diverticulosis in areas of cancer in the rectosigmoid and ascending colon was significantly lower than expected compared with the expected frequency of diverticulosis for those colonic regions. These observations suggest a true negative association between colonic neoplasia and diverticulosis.

     

The correlation between diverticulosis and redundant colon

Background

Diverticulosis and redundant colon are colonic conditions for which underlying pathophysiology, management and prevention are poorly understood. Historical papers suggest an inverse relationship between these two conditions. However, no further attempt has been made to validate this relationship. This study set out to assess the correlation between diverticulosis and colonic redundancy.

Methods

Redundant colon, diverticulosis and patient demographics were recorded during colonoscopy. Multivariate binary logistic regression was performed with redundant colon as the dependent variable and age, gender and diverticulosis as independent variables. Nagelkerke R ² and a receiver operator curve were calculated to assess goodness of fit and internally validate the multivariate model.

Results

Redundant colon and diverticulosis were diagnosed in 31 and 113 patients, respectively. The probability of redundant colon was increased by female gender odds ratio (OR) 8.4 (95% CI 2.7–26, p = 0.00020) and increasing age OR 1.7 (95% CI 1.1–2.6, p = 0.017). Paradoxically, diverticulosis strongly reduced the probability of redundant colon with OR of 0.12 (95% CI 0.42–0.32, p = 0.000039). The Nagelkerke R ² for the multivariate model was 0.29 and the area under the curve at ROC analysis was 0.81 (95% CI 0.73–0.90 p–value 3.1 × 10^?8).

Conclusions

This study found an inverse correlation between redundant colon and diverticulosis, supporting the historical suggestion that the two conditions rarely occur concurrently. The underlying principle for this relationship remains to be found. However, it may contribute to the understanding of the aetiology and pathophysiology of these colonic conditions.

     

Multiple behavioral factors are associated with occurrence of large,flat colorectal polyps

Purpose

The prevalence of advanced dysplasia and synchronous lesions is particularly high in patients with large, flat colorectal polyps. However, the impact of lifestyle on the development of such polyps is poorly investigated. Hence, this study aims to identify associations between behavioral factors and the occurrence of large, flat colorectal polyps.

Methods

Behavioral factors were retrospectively analyzed in patients with large, flat polyps and control patients with at most one diminutive polyp. Information on lifestyle factors, comorbidities, and demographic parameters were determined by a structured, self-administered questionnaire.

Results

Questionnaires of 350 patients with large, flat polyps and 489 control patients were included in the analysis. Most large, flat colorectal polyps contained adenoma with low-grade neoplasia and were located in the right colon. Multivariate analysis showed that advanced age (per 1-year increase—OR 1.09, CI 1.07–1.11, p < 0.0001), frequent cigarette smoking (OR 2.04, CI 1.25–3.32, p = 0.0041), daily consumption of red meat (OR 3.61, CI 1.00–12.96, p = 0.0492), and frequent bowel movements (OR 1.62, CI 1.13–2.33, p = 0.0093) were independent risk factors for occurrence of large, flat colorectal polyps. In contrast, frequent intake of cereals (OR 0.62, CI 0.44–0.88, p = 0.0074) was associated with a reduced risk.

Conclusion

Multiple behavioral factors modulate the risk for developing large, flat colorectal polyps. This knowledge can be used to improve prevention of colorectal cancer.

     

Selective association of nonaspirin NSAIDs with risk of diverticulitis

Purpose

The purpose of this study is to investigate the association of intake of nonsteroidal anti-inflammatory drugs (NSAIDs) and in particular nonaspirin NSAIDs and compare it with other risk factors for the progression of diverticulosis to diverticulitis in patients who underwent colonoscopy.

Methods

A total of 194 patients who underwent complete colonoscopy in our center between 2012 and 2016 were recruited: 144 with diverticulosis without prior diverticulitis (median age 71 years, 59.7% men) and 50 with diverticulitis (median age 64 years, 54.0% men). Data concerning current and previous medication as well as concomitant diseases were collected using a structured questionnaire and by revision of patients medical charts.

Results

Patients with diverticulitis were significantly (p?<?0.001) younger as compared to individuals with plain diverticulosis (median age 64 versus 71 years, respectively). The intake of NSAIDs significantly (p?=?0.002) increased the risk of prior diverticulitis (OR 3.2, 95% CI 1.5–6.9). In the multivariate model, both age (p?<?0.001) and NSAIDs (p?=?0.03) proved to be independent determinants of diverticulitis. When analyzing aspirin intake, it was not associated with diverticulitis.

Conclusions

Our study demonstrates, in line with previous reports, that intake of NSAIDs is associated with diverticulitis. We show in particular that nonaspirin NSAIDs might be selectively associated with diverticulitis. These results point to divergent role of aspirin and nonaspirin NSAIDs in the development of diverticulitis.

     

Single-incision laparoscopic versus traditional multiport laparoscopic colorectal surgery—a cumulative meta-analysis and systematic review

Purpose

The published data on the evaluation of feasibility and safety of single-incision laparoscopic colorectal surgery (SILC) compared with traditional multiport laparoscopic colorectal surgery (MLC) remained controversial. The present cumulative meta-analysis and systematic review were performed to provide a more objective and precise estimate.

Materials and methods

PubMed, the Cochrane Library, and also, manual searches were employed to identify potentially eligible studies which were published before June 7, 2012. The association was assessed by odds ratio (OR) and means with 95 % confidence intervals (CI).

Results

A total of 20 comparative studies were included, with 670 patients underwent SILC and 838 patients underwent MLC. For overall pooled estimates, no evidence of between trial differences was found in overall conversion rate (OR, 1.7; 95 % CI, 0.97 to 3.01), overall complication rate (OR, 0.82; 95 % CI, 0.63 to 1.08), and operative time (mean, ?3.59; 95 % CI, ?10.95 to 3.77); significantly between trial differences were found in estimated blood loss (mean, ?18.61; 95 % CI, ?31.33 to ?5.90) and post-operative hospital stay (mean, ?0.54; 95 % CI, ?0.95 to ?0.12). The cumulative meta-analysis identified a potentially increased conversion rate of SILC compared with MLC with the increased percentage of malignancies, but no significant differences could be identified in overall complication rate.

Conclusion

This meta-analysis suggested the feasibility and safety of SILC performed by experienced hands, though potentially higher overall conversion rate occurred in malignancies. SILC will benefit the patients much more with its superiority over MLC.     

Association study identifying polymorphisms in CD47 and other extracellular matrix pathway genes as putative prognostic markers for colorectal cancer

Purpose

We identified recently the extracellular matrix (ECM) receptor interaction pathway as a consistently overrepresented category among gene expression profiling studies on colorectal cancer (CRC) prognosis.

Methods

Putative regulatory single nucleotide polymorphisms (SNPs) in genes from the ECM pathway were genotyped in 613 CRC patients from Northern Germany (PopGen cohort) and tested for association with disease progression and survival.

Results

The eSNP (SNP associated with expression) rs12695175 in CD47 associated with CRC specific survival (HR?=?2.18, 95 % CI 1.10–4.33, CC versus AA) and with overall survival (HR?=?1.99, 95 % CI 1.04–3.81, CC versus AA). This association remained significant after adjustment for age at diagnosis, tumour stage (T) and lymph node status (N). Three polymorphisms in CD47 were associated with distant metastasis in a dominant model: rs9879947 and rs3206652 in the 3′-UTR (OR?=?1.64, 95 % CI 1.01–2.64 and OR?=?1.88, 95 % CI 1.27–2.80, respectively) and the eSNP rs3804639 (OR?=?1.73, 95 % CI 1.17–2.57).

Conclusions

The novel associations of eSNPs in CD47 with worse survival and distant metastasis should be confirmed by additional studies, since increased expression of this gene has recently been shown to be an indicator of poor prognosis in cancer patients.     

Vegetarianism as a Protective Factor for Colorectal Adenoma and Advanced Adenoma in Asians

Background

Although epidemiologic and animal studies suggest a vegetarian diet protects against the development of colorectal cancer, the relationship between vegetarian diet and incidence of colorectal adenoma is not yet conclusive, especially for Asians.

Aim

The purpose of this study was to examine the protective effect of a vegetarian diet against colorectal adenoma and advanced adenoma.

Methods

This cross-sectional study compared the prevalence of colorectal adenoma among Buddhist priests, who are obligatory vegetarians, with that among age and sex-matched controls. All the subjects underwent health checkups in a health-promotion center in Korea.

Result

Colorectal adenoma and advanced adenoma were both more prevalent in the general population group than in the Buddhist priest group (25.2 vs. 17.9 %, 6.7 vs. 2.0 %). However, the prevalence of metabolic syndrome, high body mass index, and waist circumference were higher in the Buddhist priest group. According to univariate analysis, non-vegetarian diet (general population) significantly increased the prevalence of colorectal adenoma and advanced adenoma compared with a vegetarian diet (Buddhist priests) (OR 1.54, 95 % CI 1.08–2.21, P = 0.018; OR 3.60, 95 % CI 1.53–8.48, P = 0.003). In a conditional regression analysis model, non-vegetarian diet was also a significant risk factor for colorectal adenoma and advanced adenoma (OR 1.52, 95 % CI 0.75–2.07, P = 0.043; OR 2.94, CI 0.97–7.18, P = 0.036).

Conclusions

Vegetarianism may be effective in preventing both colorectal adenoma and advanced adenoma in Asians.     

Backwash Ileitis and the Risk of Colon Neoplasia in Ulcerative Colitis Patients Undergoing Restorative Proctocolectomy

Background

The significance of backwash ileitis (BWI) relating to the risk of colon neoplasia in ulcerative colitis (UC) patients is controversial.

Aim

We investigated the association between BWI and the presence of colon neoplasia in the colectomy specimen.

Methods

From 4,198 UC patients in a prospectively maintained pouch database from 1983 to 2011, patients with extensive colitis and BWI (n = 178) in proctocolectomy were compared with 537 controls [extensive colitis (n = 385) and left-sided colitis (n = 152)] without ileal inflammation.

Results

Colon neoplasia (colon dysplasia and/or colon cancer) was seen in 32 (18 %) patients with BWI in contrast to 45 (11.7 %) with extensive colitis and 13 (8.6 %) with left-sided colitis alone (p = 0.03). Of those with BWI, colon cancer was seen in 10 patients (5.6 %), while low grade and high grade dysplasia were seen in 7 (3.9 %) and 15 (8.4 %) patients respectively. On multivariate analysis, the presence of BWI with extensive colitis [odds ratio (OR) = 3.53; 95 % confidence interval (CI) 1.01–12.30, p = 0.04], presence of primary sclerosing cholangitis (PSC) (OR = 5.79, 95 % CI 1.92–17.40, p = 0.002) and moderate to severe disease activity at UC diagnosis (OR 4.29, 95 % CI 2.06–9.01, p < 0.001) were associated with an increased risk for identifying any colon neoplasia. For colon cancer, the presence of PSC (OR = 11.30, 95 % CI 1.54–80.9, p = 0.01) was the only factor independently associated with an increased risk.

Conclusions

The presence of BWI with extensive colitis was associated with the risk of identifying colon neoplasia but not cancer alone in the proctocolectomy specimen.     

Microencapsulated sodium butyrate administered to patients with diverticulosis decreases incidence of diverticulitis—a prospective randomized study

Background

Microencapsulated sodium butyrate (MSB) has been previously associated with anti-inflammatory and regenerative properties regarding large bowel mucosa. We aimed to examine a role of MSB in patients with diverticulosis, hypothesizing its potential for reduction of diverticulitis episodes and diverticulitis prevention.

Methods

Seventy-three patients with diverticulosis (diagnosed in colonoscopy or/and barium enema or/and CT colography) were recruited for the study and randomized. The investigated group was administered MSB 300 mg daily; the control group was administered placebo. After 12 months, a total of 52 patients completed the study and were subject to analysis (30 subjects and 22 controls). During the study, the number of episodes of diverticulitis (symptomatic diagnosis with acute pain, fever, and leukocytosis), hospitalizations, and surgery performed for diverticulitis were recorded. Additionally, a question regarding subjective improvement of symptoms reflected changes in quality of life during the analysis.

Results

After 12 months, the study group noted a significantly decreased number of diverticulitis episodes in comparison to the control group. The subjective quality of life in the study group was higher than in the control group. There were no side effects of the MSB during the therapy.

Conclusions

MSB reduces the frequency of diverticulitis episodes, is safe, and improves the quality of life. It can play a role in the prevention of diverticulitis.     

Endoscopic evaluation of the colon after an episode of diverticulitis: a call for a more selective approach

Purpose

Routine colonic evaluation is advised after an episode of diverticulitis to exclude colorectal cancer. In the recent years, the possible relation between diverticulitis and colorectal cancer has been subject of debate. The aim of this study is to evaluate the benefit of routine colonic endoscopy after an episode of diverticulitis.

Methods

Records of all consecutive patients presenting with a radiologically confirmed episode of diverticulitis between 2007 and 2010 were retrieved from an in-hospital database. Patients who subsequently underwent colonic evaluation were included. The endoscopic detection rate of hyperplastic polyps, adenomas and advanced colonic neoplasia was assessed. Findings were categorized on the basis of the most advanced lesion identified.

Results

Three hundred and seven patients presented with a radiologically confirmed primary episode of diverticulitis. Two hundred and five patients underwent colonic evaluation. Hyperplastic polyps were found in15 (6.8?%), adenomas in 18 (8.8?%) and advanced neoplastic lesions in 7 (3.4?%) patients. Only two patients had a colorectal malignancy.

Conclusion

There appears to be no benefit in performing routine colonic evaluation after an episode of diverticulitis as the incidence of colorectal cancer is almost equal to that of the general population. A more selective approach might therefore be justified. Potentially, only patients with persisting abdominal complaints after an episode of diverticulitis should be offered colonic evaluation to definitively exclude causal pathology.     

Prevalence of Colorectal Neoplasia Among Young African Americans and Hispanic Americans

Background

The disproportionately higher incidence of and mortality from colorectal cancer (CRC) among African Americans (AA) led the American College of Gastroenterology to recommend screening starting at age 45 in 2005.

Aim

The purpose of this study was to determine the prevalence of colorectal neoplasia among 40–49-year-old inner city AA and Hispanic Americans (HA).

Methods

We reviewed the medical records of 2,435 inner city AA and HA who underwent colonoscopy regardless of indication and compared the prevalence of colorectal neoplasia between AA and HA patients. We used logistic regression models to calculate odds ratios (OR) and 95 % confidence intervals (CI).

Results

There were 2,163 AAs and 272 HA. There were 57 % women in both groups. A total of 158 (7 %) AA and 9 (3 %) HA (P = 0.014) underwent the procedures for CRC screening. When compared to HAs, AAs had higher prevalence of any polyp (35 vs. 18 %, OR = 2.53; 95 % CI 1.82–3.52). Overall, AA had higher prevalence of colorectal neoplasia (adenoma and cancer) when compared to HAs (16 vs. 10 %; OR = 1.68; 95 % CI 1.10–2.56).

Conclusion

We observed a higher frequency of colorectal neoplasia among 40–49-year-old AAs as compared to HAs suggesting an increased susceptibility to CRC risk in this population.     

Risk of secondary rectal cancer and colon cancer after radiotherapy for prostate cancer: a meta-analysis

Purpose

To investigate whether radiotherapy for prostate cancer increases the risk of therapy-related rectal cancer and colon cancer.

Methods

A systematic literature search was carried out using the Medline (PubMed), EMBASE, and the Cochrane Library to identify studies examining the association between radiotherapy for prostate cancer and secondary colorectal cancer (rectal cancer and colon cancer) published before March 19, 2018. The risk of second colorectal cancer after radiotherapy was summarized using unadjusted odds ratio (OR) and adjusted hazard ratio (HR) with their 95% confidence interval (CI). Subgroup and sensitivity analyses were conducted to detect potential bias and heterogeneity.

Results

After study selection, 16 reports were retrieved for analysis. When patients received radiotherapy compared with those unexposed to radiation, there was an increased risk of the rectal cancer (OR 1.37, 95%CI 1.01 to 1.85), but not colon cancer. According to adjusted HR, there was an increased risk of the rectal cancer (HR 1.64, 95%CI 1.39 to 1.94), and colon cancer (HR 1.33, 95%CI 1.02 to 1.76). The OR for rectal cancer showed an increased risk with longer latent period (5 years lag time versus 10 years lag time, OR: 1.56 versus 2.22). Brachytherapy had no association with second cancer across all analyses.

Conclusions

Radiotherapy was associated with an increased risk of subsequent rectal cancer compared with patients unexposed to radiation. Colon may be free from the damage of radiation. Brachytherapy had no association with second rectal cancer or colon cancer.

     

Self-reported snoring and metabolic syndrome: the Korean Multi-Rural Communities Cohort Study

Purpose

We investigated the association between self-reported snoring and metabolic syndrome (MetS) and its components among a community-dwelling Korean population.

Methods

A total of 7,038 subjects participated in the Korean Multi-Rural Communities Cohort Study between January 2005 and February 2010 and were included in the analysis. Frequency of snoring was classified into never, rarely (<1 day/week), occasionally (1–3 days/week), and habitually (≥4 days/week).

Results

In the fully adjusted model, compared to non-snorers, the odds ratio (OR) for MetS of snorers was significantly higher in subjects with rare snoring (OR, 1.42; 95 % confidence interval (CI), 1.23–1.64), occasional snoring (OR, 1.79; 95 % CI, 1.55–2.07), and habitual snoring (OR, 2.03; 95 % CI, 1.77–2.33) than those who did not snore. The ORs for abdominal obesity were significantly higher in rare snoring subjects (OR, 1.51; 95 % CI, 1.30–1.75), occasional snoring (OR, 1.71; 95 % CI, 1.47–1.98), and habitual snoring (OR, 2.07; 95 % CI, 1.80–2.38) than in non-snorers after adjusting for covariates.

Conclusions

Snoring was significantly and linearly associated with MetS, and this association was consistently present in both sexes. Positive and graded associations were observed between snoring frequency and MetS components including high blood pressure, elevated fasting glucose levels, and abdominal obesity, independent of conventional risk factors and other MetS components.     

Association of glucokinase regulatory gene polymorphisms with risk and severity of non-alcoholic fatty liver disease: an interaction study with adiponutrin gene

Background

Recent genome-wide association studies demonstrated an association between single nucleotide polymorphisms (SNPs) on the glucokinase regulatory gene (GCKR) with hepatic steatosis. This study attempted to investigate the association of GCKR rs780094 and rs1260326 with susceptibility to non-alcoholic fatty liver disease (NAFLD) and its severity.

Methods

The genotypes were assessed on 144 histologically confirmed NAFLD patients and 198 controls using a Sequenom MassARRAY platform.

Results

The GCKR rs1260326 and rs780094 allele T were associated with susceptibility to NAFLD (OR 1.49, 95 % CI 1.09–2.05, p = 0.012; and OR 1.51, 95 % CI 1.09–2.09, p = 0.013, respectively), non-alcoholic steatohepatitis (NASH) (OR 1.55, 95 % CI 1.10–2.17, p = 0.013; and OR 1.56, 95 % CI 1.10–2.20, p = 0.012, respectively) and NASH with significant fibrosis (OR 1.50, 95 % CI 1.01–2.21, p = 0.044; and OR 1.52, 95 % CI 1.03–2.26, p = 0.038, respectively). Following stratification by ethnicity, significant association was seen in Indian patients between the two SNPs and susceptibility to NAFLD (OR 2.64, 95 % CI 1.28–5.43, p = 0.009; and OR 4.35, 95 % CI 1.93–9.81, p < 0.0001, respectively). The joint effect of GCKR with adiponutrin rs738409 indicated greatly increased the risk of NAFLD (OR 4.14, 95 % CI 1.41–12.18, p = 0.010). Histological data showed significant association of GCKR rs1260326 with high steatosis grade (OR 1.76, 95 % CI 1.08–2.85, p = 0.04).

Conclusion

This study suggests that risk allele T of the GCKR rs780094 and rs1260326 is associated with predisposition to NAFLD and NASH with significant fibrosis. The GCKR and PNPLA3 genes interact to result in increased susceptibility to NAFLD.     

National Study of Health Insurance Type and Reasons for Emergency Department Use

BACKGROUND

The rates of emergency department (ED) utilization vary substantially by type of health insurance, but the association between health insurance type and patient-reported reasons for seeking ED care is unknown.

OBJECTIVE

We evaluated the association between health insurance type and self-perceived acuity or access issues among individuals discharged from the ED.

DESIGN, PATIENTS

This was a cross-sectional analysis of the 2011 National Health Interview Survey. Adults whose last ED visit did not result in hospitalization (n?=?4,606) were asked structured questions about reasons for seeking ED care. We classified responses as 1) perceived need for immediate evaluation (acuity issues), or 2) barriers to accessing outpatient services (access issues).

MAIN MEASURES

We analyzed survey-weighted data using multivariable logistic regression models to test the association between health insurance type and reasons for ED visits, while adjusting for sociodemographic characteristics.

KEY RESULTS

Overall, 65.0 % (95 % CI 63.0–66.9) of adults reported ≥ 1 acuity issue and 78.9 % (95 % CI 77.3–80.5) reported ≥ 1 access issue. Among those who reported no acuity issue leading to the most recent ED visit, 84.2 % reported ≥ 1 access issue. Relative to those with private insurance, adults with Medicaid (OR 1.05; 95 % CI 0.79–1.40) and those with Medicare (OR 0.98; 95 % CI 0.66–1.47) were similarly likely to seek ED care due to an acuity issue. Adults with Medicaid (OR 1.50; 95 % CI 1.06–2.13) and Medicaid + Medicare (dual eligible) (OR 1.94; 95 % CI 1.18–3.19) were more likely than those with private insurance to seek ED care for access issues.

CONCLUSION

Variability in reasons for seeking ED care among discharged patients by health insurance type may be driven more by lack of access to alternate care, rather than by differences in patient-perceived acuity. Policymakers should focus on increasing access to alternate sites of care, particularly for Medicaid beneficiaries, as well as strategies to increase care coordination that involve ED patients and providers.     

The prognostic role of matrix metalloproteinase 2 in gastric cancer: a systematic review with meta-analysis

Purpose

The prognostic role of matrix metalloproteinase 2 (MMP-2) in gastric cancer remains controversial. We systematically reviewed the evidence for assessment of MMP-2 expression in gastric cancer to elucidate this issue.

Method

Pubmed, Embase and Web of Science were searched to identify eligible studies to evaluate the association of MMP-2 expression and overall survival and clinicopathological features of gastric cancer.

Results

MMP-2 overexpression was significantly correlated with poor OS of gastric cancer patients (HR 1.92, 95 % CI 1.48–2.48). Subgroup analysis indicated that MMP-2 overexpression had an unfavorable impact on OS in Asian countries (HR 2.23, 95 % CI 1.57–3.17) and European countries (HR 1.43, 95 % CI 1.13–1.80). Furthermore, MMP-2 overexpression was significantly associated with TNM stage (TIII/TIV vs TI/TII: OR 2.17, 95 % CI 1.64–2.87), the depth of invasion (T3/T4 vs T1/T2: OR 2.59, 95 % CI 1.63–4.12), lymph node metastasis (positive vs negative: OR 2.21, 95 % CI 1.69–2.88), and distant metastasis (positive vs negative: OR 4.44, 95 % CI 1.24–15.94).

Conclusion

This meta-analysis indicated that MMP-2 overexpression might be a predictive factor for poor prognosis for gastric cancer.     

Multicenter study of endoscopic mucosal resection using 0.13 % hyaluronic acid solution of colorectal polyps less than 20 mm in size

Purpose

Endoscopic mucosal resection (EMR) of colorectal polyps should be curative and safe. This study aimed to determine the efficacy and safety of colorectal EMR using 0.13 % hyaluronic acid (HA) solution.

Methods

This was a single-armed multicenter prospective open trial conducted at 11 Japanese institutions. Lesion characteristics and various measures of clinical outcome, including en bloc resection, histopathologically complete resection, and postoperative bleeding were analyzed for 624 consecutive patients who underwent EMR of colorectal polyps at ≤20 mm in size from August 2010 to September 2011.

Results

En bloc and complete resection were achieved in 93.3 and 78.3 % of 624 lesions. The median EMR procedure time was 2.1?±?1.5 min. The rates of postoperative bleeding and perforation were 1.1 and 0 %. The rate of en bloc resection was higher for polyps at 5–10 mm than for polyps at 11–20 mm (95.1 vs. 85.1 %; P?<?0.001) and was higher for protruding polyps than for superficial polyps (94.5 vs. 87.1 %; P?<?0.05). The rate of en bloc resection was also higher for polyps in the left-side colon than for those in the right-side colon or rectum (96.7 vs. 91.6 vs. 90.8 %; P?<?0.05). Multivariate analysis showed that polyp at 11–20 mm in size and location not on the left-side colon was significantly independent risk factors for failure of en bloc resection.

Conclusion

EMR using 0.13 % HA of colorectal polyps less than 20 mm in size had high rates of en bloc and complete resection and few complications.     

Association between NQO1 C609T polymorphism and acute lymphoblastic leukemia risk: evidence from an updated meta-analysis based on 17 case–control studies

Purpose

Quinone oxidoreductase (NQO1) C609T polymorphisms have been implicated in acute lymphoblastic leukemia (ALL) risk, but previously published studies were inconsistent and recent meta-analyses were not adequate. The aim of this study was to determine more precise estimations for the relationship between the NQO1 C609T polymorphism and the risk of ALL.

Methods

Electronic searches for all publications were conducted on association between this variant and ALL in several databases updated in May 2013. The quality of studies was evaluated using the Newcastle-Ottawa Scale. Crude odds ratios (ORs) with 95 % confidence intervals (CIs) were used to assess the strength of the association. Seventeen studies were identified, including 2,264 ALL patients and 3,798 controls.

Results

Overall, significantly elevated ALL risk was associated with NQO1 C609T variant genotypes when all of the studies were pooled into the meta-analysis (TT vs. CC: OR 1.46, 95 % CI 1.18–1.79; dominant model: OR 1.45, 95 % CI 1.19–1.77). In the subgroup analysis by ethnicity, significantly increased risks were found for non-Asians (T/T vs. C/C: OR 1.74, 95 % CI 1.29–2.36; dominant model: T/T + C/T vs. C/C: OR 1.7, 95 % CI 1.27–2.29). When stratified by adult or children studies, statistically significantly elevated risks were found among adult studies (codominant model: C/T vs. C/C: OR 1.38, 95 % CI 1.02–1.87; dominant model: T/T + C/T vs. C/C: OR 1.52, 95 % CI 1.18–1.97) and children studies (recessive model: T/T vs. C/T + C/C: OR 1.34, 95 % CI 1.05–1.7).

Conclusions

Our results indicate that the C609T polymorphism of the NQO1 gene is an important genetic risk factor in ALL.