Interval for Screening Colonoscopy

What Is the Optimal Interval for Screening Colonoscopy?
At 5-year repeat colonoscopy, only 1% of 1250 participants had advanced neoplasms.

U.S. guidelines generally recommend a 10-year interval after a normal initial screening colonoscopy, but the optimal interval is uncertain. In this study, researchers examined the prevalence of abnormalities among employees of a company that offered routine colonoscopic screening at 5-year intervals.

A total of 2436 asymptomatic people (age, 50) had no adenomas on first-time screening colonoscopy; 1256 of them returned for rescreening at 5 years. One or more neoplastic polyps were found in 201 (16%) of these rescreened people, but only 16 (1.3%) had advanced neoplasms (tubular adenomas 1 cm, polyps with a villous component, or polyps with high-grade dysplasia).

Comment: In this study, people for whom initial screening colonoscopy results were normal had a very low prevalence of advanced neoplasia on 5-year follow-up colonoscopy. These findings suggest that the rescreening interval should be at least 5 years. For policy makers, a more relevant study would be a randomized trial in which 5-year and 10-year intervals are compared, but the requirement for long-term enrollment would make such a trial difficult to complete successfully. For now, we have no reason to change screening guidelines in the U.S.

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Allan S. Brett, MDPublished in Journal Watch General Medicine September 23, 2008Citation(s):Imperiale TF et al. Five-year risk of colorectal neoplasia after negative screening colonoscopy. N Engl J Med 2008 Sep 18; 359:1218.

Chesty babies - bronchiolitis

A useful update into current management of bronchiolitis - the commonest lower respiratory tract infection to affect infants.

• No evidence of benefit from antibiotics or oral steroids
• Inhaled salbutamol, theophyllines, and adrenaline do not have strong evidence for their use
• Limited evidence for antiviral ribavirin - currently used for immunosuppressed children only
• Admit to hospital if child is hypoxic, dehydrated, or high risk, eg immunosupressed (oxygen and nasogastric feeding are still the mainstays of hospital treatment)
• After bronchiolitis, a child remains likely to get respiratory symptoms like wheeze, which can last until early adolescence
• Immunisation against RSV is an option - RSV is the commonest but not only cause of bronchiolitis

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Source: Archives of Disease in Childhood 2008;93:793-798

Aspirin doesn't help memory loss

Does aspirin help to prevent memory loss if you're over 50?

We know that age related cognitive decline may be due to atherosclerosis, which aspirin helps to combat. But unfortunately, this well designed study didn't show any cognitive benefit in men and women over 50 who took daily low dose aspirin.

An editorial says that drugs that lower blood pressure are probably the best way of slowing vascular cognitive decline. Daily aspirin should be advised only for people at high risk of strokes or heart attacks and low risk of bleeding.

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Source: BMJ 2008;337:a1198

Any alternatives to warfarin?

We know that atrial fibrillation increases the risk of stroke fivefold and is the cause of a sixth of all strokes. But being on warfarin is a nuisance for our patients, and they often ask about other options. This editorial summarized the current position:

• Anticoagulation with warfarin remains the first line treatment
• Aspirin and combined antiplatelet therapy are not nearly as effective as warfarin
• Agents are being tested to replace warfarin (eg Ximelagratan, a direct thrombin inhibitor) but there is risk of liver toxicity
• Surgical techniques (ligation atrial appendage or catheter ablation) are not alternatives to warfarin
• Left atrial appendage occlusion by the catheter technique may prove to be a safe alternative for those who can't or won't take warfarin (the PROTECT atrial fibrillation study is ongoing)

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Source: Heart 2008;94:1113-1116

Pill or op for reflux?

If you had long standing acid reflux, would you take a pill or consider surgery?

This three year study compared the effectiveness and safety of a daily tablet (esomeprazole 20-40mg) versus laparoscopic antireflux surgery (LARS) for chronic gastro-oesophageal reflux disease (GORD). Both groups did well; 93% on medical treatment remained symptom free after three years, compared to 90% after surgery. There were no major postoperative complications after surgery.

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Source: Gut 2008;57:1207-1213

Preventing postop gout

After an operation, no one wants to get an attack of gout. Typically, gout starts four days after surgery, affects the big toe, and often affects several joints at once. Risk factors for getting gout after surgery are

• History of gout
• High uric acid levels (>9 g/dl)
• Surgery for cancer

To reduce the risk of gout after surgery, lower the patient's uric acid levels (preferably to below 7 mg/dl) or give colchicine to those whose levels remain high.

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Source: Annals of the Rheumatic Diseases 2008;67:1271-1275

TPA? 也許可以延到4.5小時

Good Outcomes for Thrombolysis at 3.0 to 4.5 Hours After Stroke
In a large registry study, rates of mortality, symptomatic intracerebral hemorrhage, and independence at 3 months were similar between patients treated with alteplase within 3.0 hours and patients treated at 3.0 to 4.5 hours after ischemic stroke onset.

Based on results from several studies, recombinant tissue plasminogen activator (rTPA) is approved for use in ischemic stroke only within 3 hours after symptom onset. However, other studies have suggested benefits even after a delay to treatment of more than 3 hours (JW Neurol May 20 2004). In an observational industry-sponsored study, investigators used data from an international registry of thrombolysis (involving more than 700 centers in 35 countries) to compare outcomes in 664 patients who received alteplase (0.9 mg/kg) at 3.0 to 4.5 hours after symptom onset and 11,865 patients who received it within 3 hours after onset.

Functional status at 3 months was similar in the two groups; independence (modified Rankin score 2) was achieved by 58% of patients in the group treated at 3.0 to 4.5 hours and by 56% in the group treated within 3 hours (a nonsignificant difference). Rates of symptomatic intracerebral hemorrhage within 24 hours (2.2% vs. 1.6%, respectively) and mortality at 3 months (12.7% vs. 12.2%, respectively) also did not differ significantly between groups.

Comment: Although this was not a controlled trial, the study provides evidence that thrombolysis for acute ischemic stroke can be as beneficial at 3.0 to 4.5 hours after symptom onset as within 3 hours. One caveat: The higher rates of mortality and intracerebral hemorrhage in the later-treatment group nearly reached statistical significance (at the P<0.05 level). That finding reinforces what we already know: Overall benefit from thrombolysis is clearly time dependent. Centers that are capable of performing thrombolysis within 3 hours after stroke onset should now consider doing so up to 4.5 hours after onset in patients who are appropriate candidates, particularly young patients with severe deficits. Clearly, nothing is absolute about the 3-hour time window, and thrombolysis should not be withheld for the sole reason that this amount of time has elapsed, particularly if this occurs while preparations for thrombolysis are being finalized. In light of these new findings, acute stroke services and emergency departments should revisit protocols to optimize therapeutic options for patients with this devastating condition.

— Daniel J. Pallin, MD, MPH

Citation(s): Wahlgren N et al. Thrombolysis with alteplase 3–4·5 h after acute ischaemic stroke (SITS-ISTR): An observational study. Lancet 2008 Sep 15; [e-pub ahead of print]. (http://dx.doi.org/10.1016/S0140-6736(08)61339-2)