Risk prediction rule for advanced neoplasia on screening colonoscopy for average-risk individuals

BACKGROUND In resource-limited countries,risk stratification can be used to optimize colorectal cancer screening.Few prospective risk prediction models exist for advanced neoplasia(AN)in true average-risk individuals.AIM To create and internally validate a risk prediction model for detection of AN in METHODS Prospective study of asymptomatic individuals undergoing first screening colonoscopy.Detailed characteristics including diet,exercise and medications were collected.Multivariate logistic regression was used to elucidate risk factors for AN(adenoma≥1 cm,villous histology,high-grade dysplasia or carcinoma).The model was validated through bootstrapping,and discrimination and calibration of the model were assessed.RESULTS 980 consecutive individuals(51%F;49%M)were enrolled.Adenoma and AN detection rates were 36.6%(F 29%:M 45%;P<0.001)and 5.1%(F 3.8%;M 6.5%)respectively.On multivariate analysis,predictors of AN[OR(95%CI)]were age[1.036(1.00-1.07);P=0.048],BMI[overweight 2.21(0.98-5.00);obese 3.54(1.48-8.50);P=0.018],smoking[<40 pack-years 2.01(1.01-4.01);≥40 pack-years 3.96(1.86-8.42);P=0.002],and daily red meat consumption[2.02(0.92-4.42)P=0.079].Nomograms of AN risk were developed in terms of risk factors and age separately for normal,overweight and obese individuals.The model had good discrimination and calibration.CONCLUSION The prevalence of adenoma and AN in average-risk Lebanese individuals is similar to the West.Age,smoking,and BMI are important predictors of AN,with obesity being particularly powerful.Though external validation is needed,this model provides an important platform for improved risk-stratification for screening programs in regions where universal screening is not currently employed.

Under-diagnosing and under-treating iron deficiency in hospitalized patients with gastrointestinal bleeding

AIM: To determine whether patients hospitalized with gastrointestinal(GI) blood loss anemia are being checked and treated for iron deficiency. METHODS: Retrospective chart review was conducted for all patients admitted to a single tertiary care hospital between 11/1/2011 and 1/31/2012 for any type of GI bleeding. The primary endpoint was the percentage of patients who had their iron studies checked during a hospitalization for GI blood loss anemia. Secondary outcomes included percentage of anemic GI bleeders who had adequate documentation of anemia and iron deficiency, and those who were treated for their iron deficiency. Then we tried to identify possible predictors of checking iron studies in an attempt to understand the thought process that physicians go through when managing these patients. Iron deficiency was defined as Iron saturation less than 15% or ferritin level less than 45 μg/L. Anemia was defined as hemoglobin level less than 13 g/dL for males and 12 g/dL for females.RESULTS: Three hundred and seven GI bleeders were hospitalized during the study period, and 282 of those(91.9%) had anemia during their hospital stay. Ninetyfive patients(30.9%) had iron studies performed during hospitalization, and 45 of those(47.4%) were actually found to be iron deficient. Only 29 of those 45 iron deficient patients were discharged home on iron supplements. Of the 282 patients that had anemia during hospitalization, 50(17.7%) had no documentation of the anemia in their hospital chart. Of the 45 patients that had lab proven iron deficiency anemia(IDA), only 22(48.5%) had documentation of IDA in at least one note in their chart. Predictors of checking iron studies in anemic GI bleeders were lower mean corpuscular volume, documentation of anemia, having fecal occult blood testing, not having hematemesis or past history of GI bleeding. There were no significant differences between the teaching and non-teaching services in any patient characteristics or outcomes. CONCLUSION: Iron deficiency is under-diagnosed, under-recognized even when iron studies were checked, and under-treated in hospitalized patients with GI bleeding.