Chromoendoscopy and its alternatives for colonoscopy: useful in the United States?

American endoscopists have essentially ignored chromoendoscopy (dye spraying) in the colon and overwhelmingly perform white-light colonoscopy only. The published studies suggest that routine use of chromoendoscopy in Western populations will lead to identification of additional flat lesions. However, a number of these studies have design flaws. The authors' interpretation of the existing data is that pancolonic chromoendoscopy to detect flat and depressed lesions is not yet proven as a useful and therefore necessary adjunct to routine colonoscopic examination in non-inflammatory bowel disease patients in the United States. Chromoendoscopy, particularly combined with magnification, is very effective in delineating the pit pattern of polyps and in allowing real-time differentiation of adenomatous from non-adenomatous lesions. There might be a role for chromo endoscopy with high magnification in the delineation of unresected portions of lateral spreading tumors being removed by piecemeal polypectomy and in the evaluation of polypectomy scars during endoscopic follow-up. The authors suggest that US endoscopists begin to familiarize themselves with shape classification, and that they learn a method to determine histology in real time.     

Recurrent tuberculosis in the United States and Canada: relapse or reinfection?

Recurrence of active tuberculosis after treatment can be due to relapse of infection with the same strain or reinfection with a new strain of Mycobacterium tuberculosis. The proportion of recurrent tuberculosis cases caused by reinfection has varied widely in previous studies. We evaluated cases of recurrent tuberculosis in two prospective clinical trials: a randomized study of two regimens for the last 4 months of treatment (n = 1,075) and a study of a twice-weekly rifabutin-containing regimen for human immunodeficiency virus-infected tuberculosis (n = 169). Isolates at diagnosis and from positive cultures after treatment completion underwent genotyping using IS6110 (with secondary genotyping for isolates with less than six copies of IS6110). Of 85 patients having a positive culture after completing treatment, 6 (7.1%) were classified as false-positive cultures by a review committee blinded to treatment assignment. Of the remaining 75 cases with recurrent tuberculosis and genotyping data available, 72 (96%; 95% confidence interval, 88.8-99.2%) paired isolates had the same genotype; only 3 (4%; 95% confidence interval, 0.8-11.2%) had a different genotype and were categorized as reinfection. We conclude that recurrent tuberculosis in the United States and Canada, countries with low rates of tuberculosis, is rarely due to reinfection with a new strain of M. tuberculosis.     

Top priorities for alcohol regulators in the United States: protecting public health or the alcohol industry?

Aims This paper describes alcohol industry involvement in the 2010 annual conference proceedings of the National Conference of State Liquor Administrators (NCSLA) in the United States. Design The author attended the conference, observed conference attendees and panelists and identified key themes in the panel sessions. Setting The NCSLA Annual Meeting took place 20–24 June 2010 in New Orleans, Louisiana. Participants NCSLA meeting attendees and panelists were professionals from state alcohol control systems; federal government agencies; and companies representing the alcohol industry. Measurements The total number of conference attendees and participants were counted as well as the number of attendees and participants from regulator, industry and public health sectors. Findings More than two‐thirds (72.2%) of the 187 conference attendees were from alcohol producers, importers, wholesalers, retailers or their attorneys. Nearly two‐thirds (65.0%) of the 40 panelists were from the alcohol industry. The author of this paper was the only attendee, and the only panelist, representing public health policy. Conclusions The National Conference of State Liquor Administrators in the United States is dominated by the private, global companies that produce, import, distribute and sell alcohol, highlighting a lack of public health considerations within the Association's liquor control agenda.     

Is there endoscopic capacity to provide colorectal cancer screening to the unscreened population in the United States?

BACKGROUND & AIMS: Screening rates for colorectal cancer remain low compared with screening rates for other cancers. The size of the unscreened population and the capacity to provide widespread screening are unknown. We estimated the number of average-risk persons aged 50 years or older not screened for colorectal cancer, the number of procedures required for this population, and the endoscopic capacity to satisfy this unmet need. METHODS: Using data from the US Census Bureau and the Centers for Disease Control and Prevention's National Health Interview Survey, we designed a forecasting model to estimate the number of persons in the United States currently not screened for colorectal cancer and the number of examinations needed to screen these persons. Test need was compared with available capacity, based on results from the national Survey of Endoscopic Capacity, assuming different proportions of available capacity were used for colorectal cancer screening. RESULTS: Approximately 41.8 million average-risk people aged 50 years or older have not been screened for colorectal cancer according to national guidelines. Sufficient capacity exists to screen the unscreened population within 1 year using fecal occult blood testing followed by diagnostic colonoscopy for positive tests. Depending on the proportion of available capacity used for colorectal cancer screening, it could take up to 10 years to screen the unscreened population using flexible sigmoidoscopy or colonoscopy. CONCLUSIONS: The capacity exists for widespread screening with fecal occult blood testing. The capacity for screening with flexible sigmoidoscopy or colonoscopy depends on the proportion of available capacity used for colorectal cancer screening.     

Geriatrics faculty in the United States: who are they and what are they doing?

Despite increases in geriatrics training at all levels of medical education, there is a nationwide shortage of geriatrics faculty. This shortage may be due in part to demands for clinical responsibilities that preclude adequate time for teaching and research. To learn about the professional activities of geriatrics faculty, we conducted a national survey of a 50% sample of all medical schools and their affiliated residency programs that focused on physician and non-physician geriatrics faculty in internal medicine, family practice, psychiatry, neurology, and physical medicine and rehabilitation. Although we found minor differences across specialties, in general, approximately one-third of physician faculty time is spent in teaching, the majority of which is clinical teaching. Less than 15% of physician faculty time is spent in research, and fewer than 10% of physician geriatrics faculty devote over half of their time to research. The percentage of time that non-physician faculty (other than "Research Only" faculty) spend in research is only slightly higher. These findings suggest that efforts to increase geriatrics education at all levels and promote research advances will be limited unless geriatricians devote substantially more of their time to these responsibilities.     

Dignity in older age: what do older people in the United Kingdom think?

BACKGROUND: Dignity is a complex concept and there is little empirical research to show how older people view dignity. This study, using qualitative methods, explored the concept of dignity from the older person's perspective. METHODS: 15 focus groups and two individual interviews were conducted in 12 different settings, with a total of 72 participants. Participants were purposively sampled to ensure a mix of socio-economic status, ethnicity, gender, age (65+) and level of fitness. Focus groups were audio-taped and transcribed. The method of constant comparison was used to analyse the data. RESULTS: There was strong evidence to suggest that dignity was salient to the concerns of older people. Dignity was seen as a multi-faceted concept: (i). dignity of identity (self-respect/esteem, integrity, trust); (ii). human rights (equality, choice); and (iii). autonomy (independence, control). Examples of dignity being jeopardised rather than being enhanced were given. A loss of self-esteem arose from being patronised, excluded from decision-making, and being treated as an 'object'. Lack of integrity in society meant that there was an inability to trust others and an increased vulnerability. Equality was an important issue but many felt that government policies did not support their rights. CONCLUSIONS: This work identifies the different ways dignity is conceptualised by older people. The evidence showed that person centred care for older people needs to be specifically related to communication, privacy, personal identity and feelings of vulnerability. It provides evidence for policy makers and professionals to tailor policies and practices to the needs of the older person.     

Rising incidence of intrahepatic cholangiocarcinoma in the United States: a true increase?

BACKGROUND/AIMS: The incidence of intrahepatic cholangiocarcinoma (ICC) has been reported to be increasing in the USA. The aim of this study is to examine whether this is a true increase or a reflection of improved detection or reclassification. METHODS: Using data from the Surveillance Epidemiology and End Results (SEER) program, incidence rates for ICC between 1975 and 1999 were calculated. We also calculated the proportions of cases with each tumor stage, microscopically confirmed cases, and the survival rates. RESULTS: A total of 2864 patients with ICC were identified. The incidence of ICC increased by 165% during the study period. Most of this increase occurred after 1985. There were no significant changes in the proportion of patients with unstaged cancer, localized cancer, microscopic confirmation, or with tumor size <5 cm during the period of the most significant increase. The 1-year survival rate increased significantly from 15.8% in 1975-1979 to 26.3% in 1995-1999, while 5-year survival rate remained essentially the same (2.6 vs. 3.5%). CONCLUSIONS: The incidence of ICC continues to rise in the USA. The stable proportions over time of patients with early stage disease, unstaged disease, tumor size <5 cm, and microscopic confirmation suggest a true increase of ICC.