Prophylactic PEG placement in head and neck cancer:How many feeding tubes are unused (and unnecessary)?

AIM:To determine the rate of use and non-use of prophylactic percutaneous endoscopic gastrostomy(PEG) tubes among patients with head and neck cancer(HNC) patients.METHODS:All patients with HNC undergoing PEG between January 01,2004 and June 30,2006 were identified.Patients(or their next-of-kin) were surveyed by phone and all available medical records and cancer registry data were reviewed.Prophylactic PEG was def ined as placement in the absence of dysphagia and prior to radiation or chemoradiation.Each patient with a prophylactic PEG was assessed for cancer diagnosis,type of therapy,PEG use,and complications related to PEG.RESULTS:One hundred and three patients had PEG tubes placed for HNC.Thirty four patients(33%) could not be contacted for follow-up.Of the 23(22.3%) patients with prophylactic PEG tubes,11/23(47.8%) either never used the PEG or used it for less than 2 wk.No association with PEG use vs non-use was observed for cancer diagnosis,stage,or specific cancer treatment.Non-use or limited use was observed in 3/6(50%) treated with radiation alone vs 8/17(47.1%) treated with chemoradiation(P = 1.0),and 3 of 10(30%) treated with surgery vs 8 of 13(62%) not treated with surgery(P = 0.21).Minor complications were reported in 5/23(21.7%).One(4.3%) major complication was reported.CONCLUSION:There is a high rate of unnecessary PEG placement when done prophylactically in patients with head and neck cancer.

Patient prompting of their physician resulted in increased colon cancer screening referrals

AIM:To determine whether a communication instru-ment provided to patients prior to their primary carephysician(PCP)visit initiates a conversation with theirPCP about colorectal cancer screening(CRC-S),impact-ing screening referral rates in fully insured and underin-sured patients.METHODS:A prospective randomized control studywas performed at a single academic center outpatient internal medicine(IRMC,underinsured)and fam-ily medicine(FMRC,insured)resident clinics prior to scheduled visits.In the intervention group,a pamphlet about the benefit of CRC-S and a reminder card were given to patients before the scheduled visit for prompt-ing of CRC-S referral by their PCP.The main outcome measured was frequency of CRC-S referral in each clinic after intervention.RESULTS:In the IRMC,148 patients participated,a control group of 72 patients(40F and 32M)and 76 patients(48F and 28M)in the intervention group.Re-ferrals for CRC-S occurred in 45/72(63%)of control vs 70/76(92%)in the intervention group(P≤0.001).In the FMRC,126 patients participated,66(39F:27M)con-trol and 60(33F:27M)in the intervention group.CRC-S referrals occurred in 47/66(71%)of controls vs 56/60(98%)in the intervention group(P≤0.001).CONCLUSION:Patient initiated physician prompting produced a significant referral increase for CRC-S in un-derinsured and insured patient populations.Additional investigation aimed at increasing CRC-S acceptance is warranted.

Higher dose of simethicone decreases colonic bubbles and increases prep tolerance and quality of bowel prep:Meta-analysis of randomized controlled trials

BACKGROUND Antifoaming agents,such as simethicone,may facilitate mucosal inspection during colonoscopy.However,conflicting results have been reported with regard to the impact of simethicone on quality of bowel preparation and adenoma detection rate(ADR).AIM To perform a meta-analysis of trials that have compared simethicone vs placebo during colonoscopy.METHODS A reproducible literature search of multiple medical databases yielded eleven studies(n = 2605) for inclusion.Studies were compared for quality of bowel preparation,bubbles quality,ADR,and tolerability.Two reviewers independently scored the identified studies for methodology and abstracted pertinent data.Pooling was conducted by both fixed-effects and random-effects models.Relative risk(RR) estimates with a 95% confidence interval(CI) were calculated.Heterogeneity was assessed by I-squared index(I2) statistics.RESULTS Patients' demographic characteristics were comparable in all studies.Of the 2605 patients,1300 were in the simethicone group,whereas 1305 were in the placebo group.Inadequate bowel preparation was much lower in the simethicone group than in the placebo group [13% vs 24.6%; RR = 0.51(0.31-0.82); P < 0.0001].The placebo group was more likely to have significant colonic bubbles than was the simethicone group [35% vs 8%; RR = 1.49(1.25-1.76); P = 0.0001].Use of simethicone resulted in a slight,statistically significant increase in ADR compared with the placebo group [26.6% vs 21.6%,RR = 1.07(1.01-1.13); P = 0.02].Higher doses of simethicone(> 478 mg) were more likely to result in significant reduction of inadequate bowel preparation,colonic bubbles,and to improve ADR.CONCLUSION Adding simethicone improved the quality of bowel preparation,visualization,tolerability,and,eventually,ADR.

Cirrhosis and its complications:Evidence based treatment

Cirrhosis results from progressive fibrosis and is the final outcome of all chronic liver disease. It is among the ten leading causes of death in United States. Cirrhosis can result in portal hypertension and/or hepatic dysfunction. Both of these either alone or in combination can lead to many complications, including ascites, varices, hepatic encephalopathy, hepatocellular carcinoma, hepatopulmonary syndrome, and coagulation disorders. Cirrhosis and its complications not only impair quality of life but also decrease survival. Managing patients with cirrhosis can be a challenge and requires an organized and systematic approach. Increasing physicians&#x02019; knowledge about prevention and treatment of these potential complications is important to improve patient outcomes. A literature search of the published data was performed to provide a comprehensive review regarding the management of cirrhosis and its complications.