The bowler hat: a valid sign of colonic polyps?

This report briefly describes several cases of diverticula simulating colonic mucosal lesions. We have found that the bowler hat configuration, in particular, frequently occurs in the presence of diverticular disease. In our series, no polyp was found to exhibit the bowler hat sign, while 12 cases of diverticular disease displayed 1 or more "bowler hats." Differentiation between polyps and diverticula displaying the bowler hat sign may be possible, but we conclude that the bowler hat sign per se is a nonspecific finding and that additional views may be necessary to confirm the presence of polyps.     

Endoscopic imaging: How far are we from real-time histology?

Currently,in gastrointestinal endoscopy there is increasing interest in high resolution endoscopic technologies that can complement high-definition white light endoscopy by providing real-time subcellular imaging of the epithelial surface.These ’optical biopsy’ technologies offer the potential to improve diagnostic accuracy and yield,while facilitating real-time decision-making.Although many endoscopic techniques have preliminarily shown high accuracy rates,these technologies are still evolving.This review will provide an overview of the most promising high-resolution imaging technologies,including high resolution microendoscopy,optical coherence tomography,endocytoscopy and confocal laser endoscopy.This review will also discuss the application and current limitations of these technologies for the early detection of neoplasia in Barrett’s esophagus,ulcerative colitis and colorectal cancer.     

Surveillance of colonic polyps: Are we getting it right?

Colorectal cancer(CRC) is the third most commonly diagnosed cancer worldwide. The identification of colonic polyps can reduce CRC mortality through earlier diagnosis of cancers and the removal of polyps: the precursor lesion of CRC. Following the finding and removal of colonic polyps at an initial colonoscopy, some patients are at an increased risk of developing CRC in the future. This is the rationale for postpolypectomy surveillance colonoscopy. However, not all individuals found to have colonic adenomas have a risk of CRC higher than that of the general population. This review examines the literature on post-polypectomy surveillance including current international clinical guidelines. The potential benefits of surveillance procedures must be weighed against the burden of colonoscopy: resource use, the potential for patient discomfort, and the risk of complications. Therefore surveillance colonoscopy is best utilised in a selected group of individuals at a high risk of developing cancer. Further study is needed into the specific factors conferring higher risk as well as the efficacy of surveillance in mitigating this risk. Such evidence will better inform clinicians and patients of the relative benefits of colonoscopic surveillance for the individual. In addition, the decision to continue with surveillance must be informed by the changing profile of risks and benefits of further procedures with the patient’s advancing age.     

Effects of radiation exposure from cardiac imaging: how good are the data?

Concerns about medical exposure to ionizing radiation have become heightened in recent years as a result of rapid growth in procedure volumes and the high radiation doses incurred from some procedures. This paper summarizes the evidence base undergirding concerns about radiation exposure in cardiac imaging. After classifying radiation effects, explaining terminology used to quantify the radiation received by patients, and describing typical doses from cardiac imaging procedures, this paper will address the major epidemiological studies having bearing on radiation effects at doses comparable to those received by patients undergoing cardiac imaging. These include studies of atomic bomb survivors, nuclear industry workers, and children exposed in utero to x-rays, all of which have evidenced increased cancer risks at low doses. Additional higher-dose epidemiological studies of cohorts exposed to radiation in the context of medical treatment are described and found to be generally compatible with these cardiac dose-level studies, albeit with exceptions. Using risk projection models developed by the U.S. National Academies that incorporate these data and reflect several evidence-based assumptions, cancer risk from cardiac imaging can be estimated and compared with the benefits from imaging. Several ongoing epidemiological studies will provide better understanding of radiation-associated cancer risks.     

Endoscopic snare resection of large colonic polyps: how far can we go?

BACKGROUND AND AIMS: Colonoscopic polypectomy is preventing colorectal cancer. Videoendoscopy and new perendoscopic hemostasis techniques make endoscopic polypectomy of large colonic polyps an alternative to the surgical approach. This study examined whether complete snare resection of giant colonic polyps is feasible and safe and for determining how often surgery is necessary due to invasive cancer detected histologically after polypectomy. PATIENTS AND METHODS: The study included 59 consecutive patients with 68 colonic polyps larger 30 mm in diameter. Snare polypectomy was performed after an endoscopic ultrasound with a miniprobe found no sign of invasive, or, depending on the appearance of the polyp, a bleeding prophylaxis had been carried out. Acute procedural or delayed bleeding was treated endoscopically. RESULTS: Of the 68 polyps 26, mostly pedunculated were resected en bloc (38%) and histologically ensured as completely resected; 42 polyps had to be resected by piecemeal technique (62%). Piecemeal resection was performed significantly more often in sessile polyps (38/41, 93%) than in pedunculated polyps (4/27, 15%, P<0.01). Follow-up colonoscopy after 3 months showed remaining adenomatous tissue of piecemeal-resected polyps in 12 cases (28%), which were 12 resected sessile polyps (29%) and no case of resected pedunculated polyp. To achieve complete resection of sessile polyps a second procedure was necessary significantly more often than for resection of pedunculated polyps (12 cases in sessile polyps, 18% vs. no case in pedunculated polyps). Remaining adenomatous tissue was removed in all 12 cases during the first follow-up colonoscopy after 3 months, confirmed by a biopsy 6 months after the initial procedure. Overall coexisting malignancy was found in only 7 polyps (12%). Due to high-risk factors only one of them underwent secondary surgical procedure. CONCLUSION: The present study shows that endoscopic snare resection of giant colonic polyps is a safe procedure, and that secondary operative measures for managing coexisting malignancy are rarely necessary.     

Correlation of endoscopy and histology in the gastroesophageal mucosa in children: are routine biopsies justified?

Guidelines for obtaining biopsies during endoscopy in children are needed. The endoscopic evaluation may be considered deficient on many occasions if not accompanied by a histopathologic evaluation. A retrospective review of our endoscopic records and biopsies was undertaken to determine the correlation of the visualized endoscopic appearance and the histopathologic findings in the upper gastrointestinal (GI) tract in children. Over a 1-year period, 204 patients, all of whom had esophageal biopsies and 59 of whom had gastric biopsies as well, were evaluated by an upper GI endoscopy. Endoscopic findings included erythema, granularity, abnormal vascular pattern, friability, erosions, plaques, ulceration, and strictures. Histologic evaluation of biopsies was undertaken by one pathologist according to the presence of and type of cellular infiltrate and cellular morphologic abnormalities in the mucosa and submucosa where available. In this study, the correlation of endoscopic appearance with histology was rather limited in both the esophagus and the gastric mucosa. Low specificity and sensitivity of endoscopy in both locations (41% and 81% for the esophagus; and 43% and 86% for the gastric mucosa, respectively) illustrated the discrepancy. The overall accuracy of endoscopic evaluation in matching the histologic diagnosis was not more than two out of three (63.8%). No single endoscopic finding had a reliable correlation with histologic diagnosis but some had higher predictive value than others. Of the multiple indications for endoscopy in children, recurrent abdominal pain had the least diagnostic yield. Endoscopic appearance correlates poorly with histologic diagnosis in the gastroesophageal mucosa in children. Regardless of the appearance of the mucosa, routine biopsy during upper GI endoscopy in children should be encouraged.     

Out-of-pocket costs of AIDS care in China: are free antiretroviral drugs enough?

Financial access to HIV care and treatment can be difficult for many people in China, where the government provides free antiretroviral drugs but does not cover the cost of other medically necessary components, such as lab tests and drugs for opportunistic infections. This article estimates out-of-pocket costs for treatment and care that a person living with HIV/AIDS in China might face over the course of one year. Data comes from two treatment projects run by Médecins Sans Frontières in Nanning, Guangxi Province and Xiangfan, Hubei Province. Based on the national treatment guidelines, we estimated costs for seven different patient profiles ranging from WHO Clinical Stages I through IV. We found that patients face significant financial barriers to even qualify for the free ARV program. For those who do, HIV care and treatment can be a catastrophic health expenditure, with cumulative patient contributions ranging from approximately US$200-3939/year in Nanning and US$13-1179/year in Xiangfan, depending on the patient's clinical stage of HIV infection. In Nanning, these expenses translate as up to 340% of an urban resident's annual income or 1200% for rural residents; in Xiangfan, expenses rise to 116% of annual income for city dwellers and 295% in rural areas. While providing ARV drugs free of charge is an important step, the costs of other components of care constitute important financial barriers that may exclude patients from accessing appropriate care. Such barriers can also lead to undesirable outcomes in the future, such as impoverishment of AIDS-affected households, higher ARV drug-resistance rates and greater need for complex, expensive second-line antiretroviral drugs.     

How advanced are we in targeting novel subtypes of ALL?

Despite high cure rates in children, acute lymphoblastic leukemia (ALL) remains a leading cause of cancer death in the young, and the likelihood of treatment failure increases with age. With the exception of tyrosine kinase inhibitors, there have been few advances in repurposing or developing new therapeutic approaches tailored to vulnerabilities of ALL subtypes or individual cases. Large-scale genome profiling studies conducted over the last decade promise to improve ALL outcomes by refining risk stratification and modulation of therapeutic intensity, and by identifying new targets and pathways for immunotherapy. Many of these approaches have been validated in preclinical models and now merit testing in clinical trials. This review discusses the advances in our understanding of the genomic taxonomy and ontogeny of B-progenitor ALL, with an emphasis on those discoveries of clinical importance.     

Conservative treatment of acute colonic diverticulitis: are antibiotics always mandatory?

OBJECTIVE: Most patients admitted for acute colonic diverticulitis (AD) are managed conservatively and receive antibiotics, although it is uncertain whether all patients with AD benefit from this treatment. The aim of this study was to evaluate the influence of antibiotic treatment on outcome in the conservative management of patients with mild AD. MATERIAL AND METHODS: A retrospective audit of 311 patients (64% F, mean age 60 years) hospitalized for AD was carried out. All patients were initially treated conservatively with observation and restriction of oral intake. Patients receiving antibiotics (n=118) were compared with patients treated with observation and restriction of oral intake only (n=193). Mean follow-up time (FU) was 30 months. RESULTS: Inflammation in patients treated with antibiotics was more pronounced (laboratory parameters (C-reactive protein, white blood cell count) were higher (p<0.01), fever was more common (p<0.01) and CT grading of inflammation was classified as severe in a higher proportion (p<0.01)) compared with patients treated without antibiotics. When initially treated with antibiotics, 3 patients (3%) failed to respond to treatment and had to undergo surgery. There were 7 (4%) failures in patients initially treated without antibiotics, and antibiotics were then added. During FU, 29% of patients treated with antibiotics had further events (recurrent AD and/or subsequent surgery) compared with 28% (NS) among those treated without antibiotics. In a multivariate analysis, the risk of a further event was not influenced by antibiotic treatment (OR 1.03, CI 95% 0.61-1.74). CONCLUSIONS: Our results indicate that antibiotics are not mandatory in mild AD. Treatment without antibiotics appears to be safe and seems not to change the rate of further events. These results warrant further randomized prospective studies.