Environmental contributions to gastrointestinal and liver cancer in the Asia–Pacific region

In the Asia–Pacific region, gastric, colorectal, and hepatocellular (liver) cancer show substantial regional variation in incidence consistent with the presence of important environmental factors. For gastric cancer, global incidence is concentrated in Asia with substantially higher rates in East Asia than in South‐East Asia and Australia. The differences in incidence rates for gastric cancer in the Asia–Pacific region may be due, in part, to differences in the prevalence of Helicobacter pylori infection and the prevalence of H. pylori virulence factors. Smoking is also correlated with gastric cancer risk and is responsible for the highest population attributable fraction among men in East Asia. Colorectal cancer has increased rapidly in incidence to become the third most common digestive cancer in Asia. According to cohort studies in Asia, smoking, alcohol use, obesity, and physical inactivity increase the risk of colorectal cancer. Unlike West Asia, East Asia and Australia have high incidence rates for colorectal cancer that correlates to a high Human Development Index and a high prevalence of alcohol consumption and obesity. Liver cancer is the second most common digestive cancer in Asia. The high incidence of liver cancer in East Asia and South‐East Asia is concordant with the high prevalence of hepatitis B virus and hepatitis C virus infection. Other important risk factors include alcohol use, smoking, and diabetes. The identification of the earlier and other environmental factors (currently under investigation) is central to the development and implementation of effective cancer control programs for the region.     

Hepatocellular carcinoma in the Asia pacific region

Primary liver cancer, particularly hepatocellular carcinoma (HCC) remains a significant disease worldwide. It is among the top three causes of cancer death in the Asia Pacific region because of the high prevalence of its main etiological agents, chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infections. In this region, the incidence of HCC has been static over recent decades. Older age is a major risk factor; the incidence increasing sharply after age 40 years. There is a male predilection, with male to female ratio of 3:1, except in elderly Japanese with equal sex incidence or female predominance. In most Asia‐Pacific countries, chronic HBV infection accounts for 75–80% of cases; Japan, Singapore and Australia/New Zealand are exceptions because of higher prevalence of HCV infection. In spite of advances in surgery, liver transplantation and newer pharmaco/biological therapies, the survival rate has improved only slightly over recent decades, and this could be attributable to earlier diagnosis (‘lead‐time bias’). The majority of patients present with advanced diseases, hence reducing the chance of curative treatment. The importance of HCC may decrease in two to three decades when the prevalence of chronic HBV infection decreases as a result of the universal HBV vaccination programs implemented in late 1980s in most Asia‐Pacific countries, and because of reduced incidence of medical transmission of HCV. However, transmission of HCV by injection drug use, and rising prevalence of obesity and diabetes, both independent risk factors for HCC, may partly offset this decline.     

Gastroesophageal reflux disease: An Asian perspective

The prevalence of gastroesophageal reflux disease (GERD) ranges from 2.5% to 7.1% in most population‐based studies in Asia. There is evidence that GERD and its complications are rising, coinciding with a decline in Helicobacter pylori (H. pylori) infection. Asian GERD patients share similar risk factors and pathophysiological mechanisms with their Western counterparts. Possible causes for the lower prevalence of GERD include less obesity and hiatus hernia, a lesser degree of esophageal dysmotility, a high prevalence of virulent strains of H. pylori, and low awareness. Owing to the lack of precise translation for ‘heartburn’ in most Asian languages, reflux symptoms are often overlooked or misinterpreted as dyspepsia or chest pain. Furthermore, a symptom‐based diagnosis with a therapeutic trial of the proton pump inhibitor (PPI) may be hampered by the high prevalence of H. pylori‐related disease. The risk stratification for prompt endoscopy, use of a locally‐validated, diagnostic symptom questionnaire, and response to H. pylori‘test and treat’ help improve the accuracy of the PPI test for diagnoses. PPI remain the gold standard treatment, and ‘on‐demand’ PPI have been shown to be a cost‐effective, long‐term treatment. The clinical course of GERD is benign in most patients in Asia. The risk of progression from non‐erosive reflux disease to erosive esophagitis is low, and treatment response to a conventional dose of PPI is generally higher. Although H. pylori eradication may lead to more resilient GERD in a subset of patients, the benefits of H. pylori eradication outweigh the risks, especially in Asian populations with a high incidence of gastric cancer.     

Asian consensus on the relationship between obesity and gastrointestinal and liver diseases

The incidence of obesity is increasing in Asia, with implications on gastrointestinal (GI) and liver diseases. The Gut and Obesity in Asia Workgroup comprises regional experts with the aim of studying relationship between obesity and the GI and liver diseases in Asia. Through literature review and the modified Delphi process, consensus statements examining the impact of obesity on esophageal, gastric, pancreatic, colorectal, and liver diseases, exploring relationship between gut microbiome and obesity, and assessing obesity therapies have been produced by the Gut and Obesity in Asia Workgroup. Sixteen experts participated with 9/15 statements having strong consensus (>80% agreement). The prevalence of obesity in Asia is increasing (100% percentage agreement in brackets), and this increased prevalence of obesity will result in a greater burden of obesity‐related GI and liver diseases (93.8%). There was consensus that obesity increases the risk of gastric cancer (75%) and colorectal neoplasia (87.5%). Obesity was also associated with Barrett's esophagus and esophageal adenocarcinoma (66.7%) and pancreatic cancer (66.7%) in Asia. The prevalence of non‐alcoholic fatty liver disease (NAFLD) in Asia is on the rise (100%), and the risk of NAFLD in Asia (100%) is increased by obesity. Obesity is a risk factor for the development of hepatocellular carcinoma (93.8%). Regarding therapy, it was agreed that bariatric surgery was an effective treatment modality for obesity (93.8%) but there was less agreement on its benefit for NAFLD (62.5%). These experts' consensus on obesity and GI diseases in Asia forms the basis for further research, and its translation into addressing this emerging issue.     

Colorectal neoplasm in asymptomatic Asians: a prospective multinational multicenter colonoscopy survey

BACKGROUND: Colorectal neoplasm is rapidly increasing in Asia, but a guideline for screening is not available. OBJECTIVE: To evaluate the characteristics of colorectal neoplasm in asymptomatic Asian subjects. DESIGN: Prospective cohort study. SETTING: Multinational multicenters, including both primary and referral centers in Asia. PATIENTS: A total of 860 consecutive asymptomatic adults undergoing screening colonoscopy in 11 Asian cities from July 2004 to December 2004. Patients under 16 years old; those patients with a colorectal resection history, colonoscopies, or barium enema within 5 years; symptoms suggestive of colorectal diseases; and those who had undergone surveillance colonoscopy were excluded. MAIN OUTCOME MEASUREMENTS: The incidence and distribution of colorectal neoplasm and advanced neoplasm. RESULTS: The mean age (+/-SD) was 54.4+/-11.6 years; 471 were men (54.8%). The prevalence of colorectal neoplasm and advanced neoplasm was 18.5% and 4.5%, respectively. Male sex, advancing age, and a family history of colorectal cancer were risk factors for advanced neoplasm. Of the 168 patients with colorectal neoplasm, 76 had distal neoplasm only (45.2%), 66 had proximal neoplasm only (39.3%), and 26 had both proximal and distal neoplasms (15.5%). Although the presence of distal advanced neoplasm was a significant risk factor for proximal advanced neoplasm, 14 of the 758 subjects without distal neoplasm had proximal advanced neoplasm (1.8%). LIMITATIONS: The small number of enrolled subjects, especially from certain ethnic groups. CONCLUSIONS: The overall prevalence of advanced colorectal neoplasm in asymptomatic Asians is comparable with the West. Male sex, advancing age, and a family history of colorectal cancer were associated with a higher risk of advanced neoplasm.     

Vitamin B6 intake, alcohol consumption, and colorectal cancer: a longitudinal population-based cohort of women

BACKGROUND & AIMS: Vitamin B6 has a crucial role in 1-carbon metabolism, which involves DNA synthesis and DNA methylation. Aberrations in these processes have been implicated in colorectal carcinogenesis. We examined the association between long-term dietary vitamin B6 intake and risk of colorectal cancer and whether this association is modified by consumption of alcohol, which may disrupt 1-carbon metabolism. METHODS: Our study population comprised 61,433 women in the population-based Swedish Mammography Cohort. The women were aged 40 to 76 years, had no history of cancer, and completed a food-frequency questionnaire at baseline in 1987-1990. Dietary information was updated in 1997. During a mean follow-up of 14.8 years, 805 incident colorectal cancer cases were diagnosed. RESULTS: After controlling for age and other potential confounders, long-term intake of dietary vitamin B6 was significantly inversely associated with risk of colorectal cancer (P value for trend = .002). Compared with women in the lowest quintile of vitamin B6 intake, those in the highest quintile had a 34% lower risk (multivariate rate ratio, 0.66; 95% confidence interval, 0.50-0.86). The association was most pronounced among women with moderate to high alcohol consumption. The multivariate rate ratio of colorectal cancer comparing extreme quintiles of vitamin B6 intake was 0.28 (95% confidence interval, 0.13-0.59) among women who consumed > or = 30 g/wk of alcohol (approximately equivalent to 2 drinks per week). CONCLUSIONS: Findings of this study suggest that vitamin B6 may play a role in the prevention of colorectal cancer, particularly among women who drink alcohol.     

Determination of factors responsible for the declining incidence of colorectal cancer

INTRODUCTION: After rising for 13 years in the United States, the incidence of colorectal cancer began to fall in 1986 and has continued to drop since then. This report contains an analysis of the pattern of declining colorectal cancer risk by colorectal subsite, race, and gender and a time trend investigation of suspected risk modifiers of colorectal cancer. METHOD: Colorectal cancer incidence data were obtained from the Surveillance, Epidemiology, and End Results Public Use Files from 1973 to 1994. The following exposure variables were assessed, focussing principally on the period 1970 to 1980: dietary fat, fiber, ethanolic beverages, vitamin A, vitamin C, iron, calcium, estrogen, aspirin, energy intake, body mass index, serum cholesterol, body iron stores, cholecystectomy, constipation, cigarette use, physical activity, and colonoscopic polypectomy. Data sources used in these analyses were principally National Health and Nutrition Examination Surveys I, II, and III. RESULTS: After 1985 colorectal cancer incidence declined predominantly in the distal colorectum almost equally in both white males and white females. Some exposures remained unchanged or trended in the wrong direction (dietary fat, calcium, ethanol, energy intake, physical activity, overweight prevalence, and cholecystectomy). Others did not apply equally to both genders (estrogen, aspirin, ethanol, calcium, and cholecystectomy). Others may become significant in the future, such as aspirin, estrogen, or calcium, because their supplementation is now prevalent, but were not in 1970 to 1975. Of all the risk factors or interventions assessed, the one most consistent with the observed pattern of change is increased use of colonoscopic polypectomy. CONCLUSION: The best method to diminish the incidence of colorectal cancer today may be to increase the use of screening colonoscopy and polypectomy.     

Potential health hazards of eating red meat

Red meat (beef, veal, pork, lamb and mutton) consumption contributes several important nutrients to the diet, for example essential amino acids, vitamins (including B12) and minerals (including iron and zinc). Processed red meat (ham, sausages, bacon, frankfurters, salami, etc.) undergoes treatment (curing, smoking, salting or the use of chemical preservatives and additives) to improve its shelf life and/or taste. During recent decades, consumption of red meat has been increasing globally, especially in developing countries. At the same time, there has been growing evidence that high consumption of red meat, especially of processed meat, may be associated with an increased risk of several major chronic diseases. Here, a comprehensive summary is provided of the accumulated evidence based on prospective cohort studies regarding the potential adverse health effects of red meat consumption on major chronic diseases, such as diabetes, coronary heart disease, heart failure, stroke and cancer at several sites, and mortality. Risk estimates from pooled analyses and meta‐analyses are presented together with recently published findings. Based on at least six cohorts, summary results for the consumption of unprocessed red meat of 100 g day^?1 varied from nonsignificant to statistically significantly increased risk (11% for stroke and for breast cancer, 15% for cardiovascular mortality, 17% for colorectal and 19% for advanced prostate cancer); for the consumption of 50 g day^?1 processed meat, the risks were statistically significantly increased for most of the studied diseases (4% for total prostate cancer, 8% for cancer mortality, 9% for breast, 18% for colorectal and 19% for pancreatic cancer, 13% for stroke, 22% for total and 24% for cardiovascular mortality and 32% for diabetes). Potential biological mechanisms underlying the observed risks and the environmental impact of red meat production are also discussed. The evidence‐based integrated message is that it is plausible to conclude that high consumption of red meat, and especially processed meat, is associated with an increased risk of several major chronic diseases and preterm mortality. Production of red meat involves an environmental burden. Therefore, some European countries have already integrated these two issues, human health and the ‘health of the planet’, into new dietary guidelines and recommended limiting consumption of red meat.     

Riesgo de adenomas colorrectales en pacientes con enfermedad celiaca: una revisión sistemática y metaanálisis

Introduction and aims

Whether celiac disease increases the risk of presenting with colorectal adenoma or not, has not been extensively evaluated. This question becomes relevant when considering early screening methods in patients with the disease. The aim of our article was to determine the risk of colorectal adenomas in celiac disease patients.

Processed foods and the nutrition transition: evidence from Asia

This paper elucidates the role of processed foods and beverages in the ‘nutrition transition’ underway in Asia. Processed foods tend to be high in nutrients associated with obesity and diet‐related non‐communicable diseases: refined sugar, salt, saturated and trans‐fats. This paper identifies the most significant ‘product vectors’ for these nutrients and describes changes in their consumption in a selection of Asian countries. Sugar, salt and fat consumption from processed foods has plateaued in high‐income countries, but has rapidly increased in the lower–middle and upper–middle‐income countries. Relative to sugar and salt, fat consumption in the upper–middle‐ and lower–middle‐income countries is converging most rapidly with that of high‐income countries. Carbonated soft drinks, baked goods, and oils and fats are the most significant vectors for sugar, salt and fat respectively. At the regional level there appears to be convergence in consumption patterns of processed foods, but country‐level divergences including high levels of consumption of oils and fats in Malaysia, and soft drinks in the Philippines and Thailand. This analysis suggests that more action is needed by policy‐makers to prevent or mitigate processed food consumption. Comprehensive policy and regulatory approaches are most likely to be effective in achieving these goals.     

Risk factors for colorectal adenomas among immediate family members of patients with colorectal cancer in Taiwan: a case-control study

OBJECTIVES: The incidence of colorectal cancer or adenoma among first-degree relatives of patients with colorectal cancer is significantly high. However, a well defined screening and surveillance consensus has not been developed for these families in Taiwan. We conducted this study to evaluate the colorectal adenoma prevalence pattern in screened immediate family members in Taiwan, and to derive implications for future screening programs. METHODS: A total of 234 immediate family members (aged 51.6 +/- 21.5 yr) of 186 patients with colorectal cancer were offered a colonoscopy. Each relative examined was then paired with two control subjects for age, sex, and symptoms. The prevalence of colorectal adenomas was then compared using multiple logistic regression analysis. RESULTS: The estimated risk of developing adenomas among immediate family members of patients with colorectal cancer was significantly increased (OR = 2.33; 95% CI, 1.43-3.78; p < 0.001). This trend was more striking for men (OR = 2.46; 95% CI, 1.40-4.31; p = 0.001). Immediate family members were at an increased risk for high-risk adenomas (> or = 1.0 cm, with a villous component, and/or with severe dysplasia) (OR = 4.5; 95% CI, 1.91-10.60; p = 0.002), and developed adenomas at an earlier age than did controls. Individuals with index cancer relatives diagnosed at < 50 yr of age or male relatives posed a higher risk of developing colorectal adenomas. CONCLUSIONS: The prevalence of colorectal adenoma in persons with a colorectal cancer family history in Taiwan is similar to that reported in Western countries. This high-risk population should be offered a screening colonoscopy beginning at 40 yr of age.     

河南省结直肠癌患者蓝氏贾第鞭毛虫感染及危险因素分析

目的　了解河南省结直肠癌患者蓝氏贾第鞭毛虫感染特征并分析其危险因素。方法　2021年3—7月,采用横断面调查法对河南省肿瘤医院结直肠癌患者进行问卷调查,并收集其粪便样本,采用巢式PCR法扩增蓝氏贾第鞭毛虫磷酸丙糖异构酶（tpi）基因以确定感染虫种基因型。采用单因素分析和多因素logistic回归模型分析结直肠癌患者感染蓝氏贾第鞭毛虫的危险因素。结果　共调查结直肠癌患者307例,其中男性176例（占57.3%）、女性131例（占42.7%）。巢式PCR检测粪样基因组DNA发现,蓝氏贾第鞭毛虫感染率为8.1%[25/307,95% 可信区间（CI）:（0.056,0.117）],其中男性感染率为9.1%[16/176,95% CI:（0.057,0.143）]、女性感染率为6.9%[9/131,95% CI:（0.037,0.125）]（[χ2] = 0.495,P = 0.482）。不同年龄组结直肠癌患者蓝氏贾第鞭毛虫感染率差异无统计学意义（[χ2] = 1.534,P = 0.675）。多因素分析发现,使用粪池[比值比（OR）= 3.336,95% CI:（1.201,9.267）]、日常使用水井水[OR = 3.042,95% CI:（1.093,8.465）]及饲养家畜[OR = 3.740,95% CI：（1.154,12.121）]是结直肠癌患者感染蓝氏贾第鞭毛虫的危险因素。结直肠癌患者中,蓝氏贾第鞭毛虫感染者腹痛发生率显著高于非感染者（P = 0.017）。25例蓝氏贾第鞭毛虫感染者中,24例（占96.0%）为聚集体A型感染、1例（占4.0%）为聚集体B型感染。结论　河南省结直肠癌患者蓝氏贾第鞭毛虫感染率相对较高,感染的蓝氏贾第鞭毛虫主要基因型为聚集体A型;使用粪池、日常使用水井水及饲养家畜是结直肠癌患者感染蓝氏贾第鞭毛虫的危险因素。     

Relationship between meat and cereal consumption and colorectal cancer in Korea and Japan

Background and Aim: The incidence of colorectal cancer in Asian countries is increasing. The change to a more westernized diet is known to be related to these increases, and there are reports on the relationship between meat consumption and colorectal cancer in Japan. The aim of this study was to investigate the relationship between dietary change and colorectal cancer in Korea and Japan. Methods: The data of meat and cereal consumption in Japan (1950–2002) and Korea (1970–2003), and the data of colorectal cancer incidence in Japan (1975–1998) and Korea (1992–2002) were investigated with a 20‐year difference between the two countries. Result: We found that the changes in meat and cereal consumption, as well as the increases in the incidence of colon and rectal cancer, were similar between those two countries with a 20‐year difference. Conclusion: These similarities between Korea and Japan could be helpful for predicting future colorectal cancer incidences for Korea and other Asian countries.     

Age differences in diagnostic criteria of DSM-IV alcohol dependence among adults with similar drinking behaviour

Aims To test age differences in the prevalence of DSM‐IV alcohol dependence (AD) diagnostic criteria in the adult general population while controlling for drinking behaviour. Design and setting Cross‐sectional data from the 2006 German Epidemiological Survey of Substance Abuse (ESA) were used, applying a two‐stage probability sampling design. The survey used self‐administered questionnaires and telephone interviews (mixed‐mode design; 45% response rate). Participants The analytical sample consisted of n = 6984 individuals aged 18–64 years reporting alcohol consumption within the previous year. Measurements Age effects on individual AD criteria were estimated using logistic regression models, adjusting for eight mutually exclusive drinking groups (defined in terms of average daily alcohol intake and episodic heavy drinking) and socio‐economic variables. Findings When controlling for drinking behaviour, 18–24‐year‐olds were more likely to meet the criteria ‘tolerance’, ‘larger/longer’ and ‘time spent’ relative to older age groups. In contrast, the likelihood of experiencing ‘withdrawal’ symptoms increased with age. There was no significant age effect on the diagnosis of AD. Conclusions Age differences in the prevalence of specific alcohol dependence diagnostic criteria such as ‘tolerance’, ‘drinking larger amount or for longer than intended’ and ‘time spent recovering’ cannot be fully explained by differences in drinking behaviour.     

IMPROVED BALLOON‐TIPPED TRANS‐ANAL ILEUS TUBE

Background: For management of bowel obstruction due to colorectal cancer, endoscopic trans‐anal decompression technique has been first reported by Lelcuk et al. in 1986 using balloon dilatation technique. Since then, various types of trans‐anal decompression tubes have been clinically used for patients suffering from left side obstructing colorectal cancer as an emergent decompressing device. At present, two types of trans‐anal ileus tube (trans‐anal decompression tube) have been available for clinical use, but they have two main problems that are late colon perforations caused by the tip of the tube and tube obstruction by stool. Methods: Analysis on three late colon perforations experienced with the use of conventional devices drew possible improvements to make a trans‐anal ileus tube less harmful. To overcome the pitfalls inherent to conventional tubes, the author has developed an improved trans‐anal ileus tube with a balloon installed at the very end of the tube (‘balloon‐tipped type’) made of silicone, measuring 1200 or 1700 mm in total length and 22 Fr in outer diameter. It has been used for 12 cases with obstructing colorectal cancer etc. and its outcomes were compared with those obtained by the use of conventional trans‐anal ileus tube. Results: No late perforations have been encountered, but tube obstruction did occur in one of 12 cases. Conclusion: The new trans‐anal ileus tube with a balloon installed at the tip of ileus tube is considered to be safer and especially effective in preventing late colon perforation and tube obstruction.     

Changing trends in gastrointestinal disease in the Asia-Pacific region

The new millennium has seen distinct changes in the pattern of gastrointestinal disease in the Asia-Pacific region. These changes are important as more than half of the world's population come from the region and therefore impact significantly on the global disease burden. The highest incidence of gastric cancer (GCA) has been reported from Asia and GCA remains a very important cancer. However time-trend studies have shown a decrease in GCA incidence in several countries in Asia. A rise in cardio-esophageal cancers as seen in the West has not been reported. On the other hand, colorectal cancer has been steadily increasing in Asia with age-standardized incidence rates of some countries approaching that of the West. The pattern of acid-related diseases has also changed. Gastroesophageal reflux disease is a fast emerging disease with an increasing prevalence of reflux esophagitis and reflux symptoms. The prevalence of peptic ulcer disease has at the same time declined in step with a decrease in H. pylori infection. Many of the changes taking place mirror the Western experience of several decades ago. Astute observation of the epidemiology of emerging diseases combined with good scientific work will allow a clearer understanding of the key processes underlying these changes. With rapid modernization, lifestyle changes have been blamed for an increase in several diseases including gastroesophageal reflux disease, nonalcoholic fatty liver disease and colorectal cancer. A worrying trend has been the increase in obesity among Asians, which has been associated with an increase in metabolic diseases and various gastrointestinal cancers. Conversely, an improvement in living conditions has been closely linked to the decrease in GCA and H. pylori prevalence.     

Colonic Neoplasia in Asymptomatic Persons with Negative Fecal Occult Blood Tests: Influence of Age, Gender, and Family History

Six hundred twenty-one asymptomatic persons with negative fecal occult blood tests (ages 50–75 yr), including 496 with no known risk factors for colorectal cancer and 125 with a single first-degree relative with a history of colonic neoplasia developed after age 40, underwent screening colonoscopy. Three Dukes A cancers were detected in average-risk persons. The overall prevalence of adenomatous polyps was 27%. Multiple logistic regression analysis revealed that increasing age and male gender were both strong predictors of colonic neoplasia ( p < 0.001). A positive family history of a single first-degree relative with colorectal cancer was not associated with an increased prevalence of colonic neoplasia ( p = 0.29), although an effect may be present if the relative was <60 yr at diagnosis. Overall 16% of males and 7% of women > 60 yr had at least one adenoma that was large (>1 cm in size), villous or tubulovillous, or had grade 3 dysplasia. We conclude that the prevalence of colonic neoplasia in asymptomatic persons with negative fecal occult blood tests is substantial, particularly in elderly males. A family history of a single first-degree relative diagnosed at age >60 yr with colorectal cancer is not associated with an increased prevalence of colonic adenomas.     

Estimating prevalence of problem drug use at national level in countries of the European Union and Norway

Objectives This paper will present the most recent estimates for problematic drug use in European Member States and explore the problems of comparability. Methods Estimates of problematic drug use, derived according to agreed guidelines, were collected from all EU countries and Norway. Methods included multipliers based on treatment, police, mortality or AIDS/HIV data, the capture–recapture method and the multivariate indicator method. Prevalence estimates were transformed into rates per 1000 population aged 15–64 years. Results Target populations varied according to data selection. Estimates for six partially overlapping types of drug use could be identified: ‘problem opiate use’, ‘problem opiate or cocaine use’, ‘problem amphetamine or opiate use’, ‘problem drug use’, ‘(current) injecting’ and ‘life‐time injecting’. Rates of injectors ranged from 2.6 in Germany to 4.8 in Luxembourg; rates in Austria, Denmark, Finland, Portugal and the United Kingdom fell within this range. For problem opiate use, a group of high prevalence countries were found with average rates exceeding six cases (Italy, Luxembourg, Spain and the United Kingdom) and a group with lower prevalence with average rates close to three cases (Austria, Germany, Ireland, the Netherlands). Rates obtained for France (problem opiate or cocaine use), Finland and Sweden (problem amphetamine or opiate use) are not directly comparable and fall between these rates. Conclusions Cross‐national comparisons should be made with care and estimated target populations may vary greatly between countries. For estimating various forms of problem drug use at national level, a multi‐method approach is recommended.     

Endoscopic mucosal resection of colorectal tumors

It has been possible to resect early colorectal cancer by endoscopy due to the progress of colonoscopic diagnosis and technology. Therefore, most cases of colorectal mucosal cancer and benign tumor have been resected by endoscopy only. We report some techniques for endoscopic resection of colorectal tumors. The technique of endoscopic resection: (i) The B‐Wave bipolar snare device: It is difficult to resect flat lesions that are not sufficiently elevated to be ligated by a usual snare. The snare of the B‐Wave bipolar snare device is coated to prevent slipping on the colorectal mucosa. (ii) ‘Sculpting down’ polypectomy: It is difficult to resect large sessile lesions because the bases of these lesions cannot be well observed endoscopically. ‘Sculpting down’ polypectomy is a useful method for safe resection of such tumors. (iii) Endoscopic resection through a retroflexed scope: Under retroverted colonoscopic observation, submucosal injection and partial resection is performed. Then, under ordinary observation, complete resection of the residual tumor is performed. (iv) Endoscopic mucosal resection using a cap‐fitted panendoscope (EMRC): EMRC is useful for lesions located in the lower rectum because there is no risk of free perforation. At first, submucosal injection is performed. The snare is set in the transparent cap and the lesion is aspirated into the cap. Then, it is snared and resected.     

The prevalence and psychological correlates of anorexia nervosa,bulimia nervosa and binge eating among 15‐year‐old students: a controlled epidemiological study

The present study reports on the prevalence of adolescent anorexia nervosa, bulimia nervosa and binge eating disorders. Also, the hypothesis by Slade (1982) suggesting ‘perfectionism’ and ‘general dissatisfaction’ as setting conditions for eating disorders was tested. A total of 678 15‐year‐old adolescents were screened, and those who scored above 10 on the ‘drive for thinness’ subscale on the Eating Disorder Inventory (EDI) were interviewed for suspected eating disorders. A gender‐ and age‐matched control group of low scores were also clinically interviewed. The interviewers were blind to whether individuals were suspected of having eating disorders or not. The Setting Conditions for Anorexia Nervosa Scale (SCANS) was used to test the setting condition hypothesis. Other variables included were the EDI subscales ‘Bulimia’ and ‘Body dissatisfaction’. Weight was calculated using the Body Mass Index. For the total material, we found 1.0 per cent with a binge eating disorder, 0.7 per cent with bulimia nervosa, 0.3 per cent with a bulimic subtype of anorexia nervosa and 0.7 per cent with subclinical bulimia nervosa. All subjects were girls. In addition, 3.5 per cent were considered ‘at risk’, of whom we identified 22 girls (3.2 per cent) and two boys (0.3 per cent). High scores on ‘perfectionism’ were unrelated to the presence of eating disorders. Controlling for ‘body dissatisfaction’, ‘general dissatisfaction’, on the other hand, was related to eating disorders and an ‘at‐risk’ condition. The prevalence figures in this age cohort equal those for older age groups. The weak support to the setting condition hypothesis may point to an inadequate instrument and not necessarily to a theoretically blind alley. Copyright © 1999 John Wiley & Sons, Ltd and Eating Disorders Association.