Forthcoming Step in Gastric Cancer Prevention: How Can Risk Stratification Be Combined with Endoscopic Screening for Gastric Cancer?

Although the concern for gastric cancer prevention has increased, gastric cancer has remained a heavy burden worldwide and is not just a local issue in East Asian countries. However, as several screening programs (listed below) have shown some success, it is important to determine whether the situation is changing in some other countries and whether similar methods should be recommended. Endoscopic screening has been performed as a national program in South Korea and Japan, and the results have shown a reduction in gastric cancer mortality. Although the efficacy of Helicobacter pylori eradication has been established, the efficacy of the screen-and-treat strategy is presently being evaluated in randomized controlled trials. The serum pepsinogen test and endoscopic examination can divide high-risk subjects with severe gastric atrophy from average-risk subjects. Risk stratification is anticipated to contribute to an efficient method of prediction of gastric cancer development when combined with endoscopic screening. Countries with a high incidence rate should realize the immediate need to reduce gastric cancer death directly by endoscopic screening and should recognize screen-and-treat as a second option to reduce future risk. However, all forms of gastric cancer prevention programs have some harms and potential to increase unnecessary examinations. A balance of the benefits and harms should be always considered. Although further study is needed to obtain sufficient evidence for gastric cancer prevention, the best available method should be examined in the context of each country.     

Can Hip Protector Use in the Nursing Home Be Predicted?

OBJECTIVES: To identify resident- and caregiver-related factors that influence hip protector (HP) usage. DESIGN: Prospective observational cohort study over 6 weeks. SETTING: A 409-bed nursing home located in New York City. PARTICIPANTS: Fifty-two residents and 60 certified nursing assistants (CNAs). INTERVENTION: Free HPs were provided to residents enrolled in the study. MEASUREMENTS: HP adherence (number of hours HPs were worn/shift); HP users (subjects who used HPs for more than 1 hour during any 8-hour shift as recorded by CNAs in week 6 or who used HPs at checks performed by research staff in week 6 and intended future use); CNAs' scores on a questionnaire quantifying osteoporosis knowledge, opinions on HPs, job satisfaction, and health locus of control. RESULTS: Sixty-eight percent of residents were HP users. Factors independently associated with this outcome included male sex, age, Parkinson's disease, family involvement, impaired cognition, dependent ambulation, and CNAs' sense that chance affects health outcomes. In multivariate models, anxiety, resistive behaviors, ambulation, and fall history in residents and CNAs' perceptions of HPs and their sense of how chance or other staff determine health outcomes predicted HP adherence. CONCLUSION: Resident-related factors and CNAs' sense of external controls predicted HP users and HP adherence. CNAs' understanding of osteoporosis and HP affected only HP adherence. Most resident-related factors were not remediable but might help to target likely HP users. To improve HP adherence, educational programs should be designed to improve CNAs' understanding of osteoporosis and HP. Larger studies are needed to confirm these findings.     

How Can Psoriatic Arthritis Be Diagnosed Early?

Psoriatic arthritis (PsA) is an inflammatory arthritis that usually develops after the onset of cutaneous psoriasis. Early diagnosis of PsA may lead to less joint damage and better long-term outcomes. Identifying inflammatory arthritis in individuals with psoriasis is the key to early diagnosis of PsA. Screening strategies targeted at individuals with psoriasis, as well as family members of patients with PsA will result in early identification of PsA. This article describes the various strategies that could be employed to identify inflammatory arthritis in patients with psoriasis so that appropriate referral to a rheumatologist for early diagnosis of PsA may be made.     

Is Endoscopic Resection an Acceptable Treatment for Undifferentiated EGC?

Background/Aims: Endoscopic resection (ER) is an effective treatment in selected patients with early gastric cancer (EGC). We have evaluated the clinical outcomes of ER in patients with undifferentiated EGCs, including poorly differentiated adenocarcinoma or signet ring cell carcinoma. Methodology: We retrospectively examined the medical records of 77 patients diagnosed with undifferentiated EGC after ER (EMR for 22 patients and ESD for 56 patients) at a single center. Results: The mean±SD lesion size was 23.2±14.1mm. The 77 lesions included 65 (84.4%) intramucosal cancers and 12 (15.6%) involving the submucosal layer. Of these 77 patients, 35 underwent curative resection and 42 did not. After a mean follow-up period of 41 months (range, 9-152), local recurrences were observed in four patients (5.2%), all of whom had not undergone curative resection. No patient died of EGC. Univariate analysis showed that tumor involvement of the resection margins (p<0.001) and lymphatic invasion (p=0.003) were significant risk factors for recurrence after ER in undifferentiated EGCs. However, multivariate analysis did not show any significant risk factors. Conclusions: ER may be an alternative treatment modality for selected patients with undifferentiated EGCs.     

Refractory Ascites: How to Establish the Diagnosis and What Can Be Done?

Refractory ascites accounts for 5-10 % of all ascites and portends a very poor prognosis. Refractory ascites can be diuretic-resistant (unresponsive to maximal dose of diuretics) or diuretic-intractable (inability to use an effective dose of diuretics due to development of complications). Management is challenging as therapeutic options are limited. Available options include serial large volume paracentesis or placement of transjugular intrahepatic portosystemic shunt. A novel device involving an automated low flow ascites pump and a peritoneo-vesical shunt has been recently developed but long term safety and efficacy data are awaited. Liver transplantation is the only modality proven to improve long-term survival.     

Endoscopic ultrasound-guided techniques for diagnosing pancreatic mass lesions: Can we do better?

The diagnostic approach to a possible pancreatic mass lesion relies first upon various non-invasive imaging modalities, including computed tomography, ultrasound, and magnetic resonance imaging techniques. Once a suspect lesion has been identified, tissue acquisition for characterization of the lesion is often paramount in developing an individualized therapeutic approach. Given the high prevalence and mortality associated with pancreatic cancer, an ideal approach to diagnosing pancreatic mass lesions would be safe, highly sensitive, and reproducible across various practice settings. Tools, in addition to radiologic imaging, currently employed in the initial evaluation of a patient with a pancreatic mass lesion include serum tumor markers, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasound-guided fine needle aspiration(EUS-FNA). EUS-FNA has grown to become the gold standard in tissue diagnosis of pancreatic lesions.     

What Can We Do to Optimize Colonoscopy and How Effective Can We Be?

In the USA, colorectal cancer is the third most common cancer and third leading cause of cancer death among both men and women. Declining rates of colon cancer in the past decade have been attributed in part to screening and removal of precancerous polyps via colonoscopy. Recent emphasis has been placed on measures to increase the quality and effectiveness of colonoscopy. These have been divided into pre-procedure quality metrics (bowel preparation), procedural quality metrics (cecal intubation, withdrawal time, and adenoma detection rate), post-procedure metrics (surveillance interval), and other quality metrics (patient satisfaction and willingness to repeat the procedure). The purpose of this article is to review the data and controversies surrounding each of these and identify ways to optimize the performance of colonoscopy.