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Colorectal cancer (CRC) continues to be one of the most commonly diagnosed cancers and contributes significantly to many cancer-related deaths despite sustained progress in diagnostic and treatment options. Many forms of CRC can be prevented through early and routine screening, when precancerous lesions may be detected and removed before they undergo malignant transformation or metastasis. Despite widespread efforts to improve CRC screening rates, at least 40% of age-eligible adults do not adhere to screening guidelines. A new generation of noninvasive, molecular-based diagnostic tests with high sensitivities and specificities has the potential to improve screening rates through optimal risk stratification of patients who may benefit from more invasive screening techniques. This review presents various guidelines and methods that are currently available for CRC screening, summarizes the rationale behind utilization of novel molecular-based diagnostic tests for CRC screening and prevention, and discusses appropriate screening techniques and intervals in populations of varying risk.

Benign synovial diseases of the hip including Synovial Chondromatosis (SC) and Pigmented Villonodular Synovitis (PVNS) are devastating diseases. Initially, patients present with hip pain unrelieved by conservative measures. The diagnosis of PVNS and SC are often delayed, leading to progression of joint damage. The purpose of this review is to present the latest on the diagnosis, management, and prognosis of SC and PVNS of the hip.An extensive systematic search of MEDLINE and PUBMED Databases was performed. Data parameters were set from 2005 to present day with set inclusion criteria. Systematic reviews were excluded.427 abstracts were identified, with 12 articles meeting all inclusion criteria. Eight studies focused on SC, and 5 on PVNS. 233 patients with SC of the hip and 98 patients with PVNS of the hip were identified, a total of 331 patients.Benign Synovial disorders of the hip are rare. In patients with chronic hip pain secondary to benign synovial disorders, early diagnosis and surgical intervention demonstrate good outcomes, and patients may benefit due to prevention of morbidity from further joint destruction. There is no clear consensus between higher successes through open versus arthroscopic surgical debridement. In the final phase of benign synovial disorders of the hip, THA of different types based on the patient's age should be considered.

Aliment Pharmacol Ther 2011; 33: 149–159 Summary Background Effectiveness of medical therapies in chronic pancreatitis has been described in small studies of selected patients. Aim To describe frequency and perceived effectiveness of non-analgesic medical therapies in chronic pancreatitis patients evaluated at US referral centres. Methods Using data on 516 chronic pancreatitis patients enrolled prospectively in the NAPS2 Study, we evaluated how often medical therapies [pancreatic enzyme replacement therapy (PERT), vitamins/antioxidants (AO), octreotide, coeliac plexus block (CPB)] were utilized and considered useful by physicians. Results Oral PERT was commonly used (70%), more frequently in the presence of exocrine insufficiency (EI) (88% vs. 61%, P

Background: The role of combined localized positron emission tomography (lPET) and computed tomography enterography (CTe) in Crohn's disease is unclear. We examined if this imaging modality using fluorine-18 labeled-fluoro-2-deoxy-D-glucose (FDG) could more effectively identify disease activity. Methods: 52 lPET-CTe scans were analyzed in this retrospective study. CTe scores and FDG uptake were quantified. Correlations of CTe scores and standard uptake value (SUV) with C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), short Inflammatory Bowel Disease Questionnaire (sIBDq), and Harvey–Bradshaw index (HBI) were estimated using Pearson analysis. Imaging scores were compared to medical outcome by logistics regression model. Results: CTe scores correlated with SUV, but additional abnormal segments of small bowel were not identified. In all, 38 (79%) abnormal CTe segments demonstrated increased FDG uptake with mean SUVmax 4.77; 10 (21%) abnormal CTe segments lacked FDG accumulation, with mean SUVmax 1.27. There was no correlation between SUVmax and CRP, ESR, sIBDq, or HBI. There were no significant differences in clinical indices, biochemical parameters, and presence of multiple abnormal segments between medical responders and uptake were associated with failed medical therapy (P = 0.001). Conclusions: PET scanning added to CTe did not identify additional abnormal segments when compared to CTe alone. Abnormal segments with mucosal enhancement on CTe that did not accumulate FDG were significantly associated with failure of medical therapy. A larger trial is warranted to confirm if combined lPET-CTe has an important role in the clinical management of stricturing Crohn's disease. (Inflamm Bowel Dis 2009;)

We report principal component analysis (PCA) of (1)H NMR spectra recorded for a group of human lung carcinoma cell lines in culture and (1)H NMR analysis of extracts from the same samples. The samples studied were cells of lung tumour origin with different chemotherapy drug resistance patterns. For whole cells, it was found that the statistically significant causes of spectral variation were an increase in the choline and a decrease in the methylene mobile lipid (1)H resonance intensities, which correlate with our knowledge of the level of resistance displayed by the different cells. Similarly, in the (1)H NMR spectra of the aqueous and lipophilic extracts, significant quantitative differences in the metabolite distributions were apparent, which are consistent with the PCA results.

Abdominal pain related to pancreatic cancer or chronic pancreatitis can be a disabling and difficult symptom to treat for patients, their families, and physicians. Pharmacologic therapy with nonsteroidal anti-inflammatory drugs is usually ineffective. Opiate analgesics may not be well tolerated and can lead to dependence. Endoscopic ultrasound-guided celiac plexus block offers a potential adjunct treatment for pain control.

Our goal was to evaluate the 90/90 pillow as an effective means of preventing blood loss after knee arthroplasty. We performed a prospective randomized case-control study on 40 patients undergoing knee arthroplasty. All patients were treated in a standard fashion, except for the use of the 90/90 pillow in one group. The 90/90 pillow flexes the knee to 90° and is in situ for 24 hours after surgery. We measured blood loss at time points from 1 to 48 hours. Range of motion was assessed, as were analgesic requirements. Statistical analysis was performed on our results. We found a statistically significant reduction in blood loss without compromising range of motion. We advocate the 90/90 pillow after all knee arthroplasties.

Species delimitation in Taxus (Taxaceae) has been controversial due to high levels of phenotypic plasticity. Reputed hybrids between species have been questioned due to the original crosses' accidental nature and the uncertainty regarding the parent species' distinctness. In this study 19 samples from three species (T. baccata, T. canadensis, T. cuspidata) and 31 from putative hybrids (T. × hunnewelliana, T. × media) have been DNA-fingerprinted using RAPDs and characterized for their respective chloroplast genotype using restriction digestions of polymerase chain reaction- (PCR) amplified trnL-F fragments. All samples showed unique RAPD banding profiles. Twenty-one RAPD bands were species-specific; the presence of these bands in the putative hybrids confirmed the hybrid origin and parentage suspected from morphological studies (T. cuspidata × T. canadensis = T. × hunnewelliana, T. baccata × T. cuspidata = T. × media). Principal coordinates analysis (PCO) and unweighted pair-group method algorithm (UPGMA) analyses of RAPD bands clearly separated the species, indicating that they belong to discrete genetic stocks and supporting their individual species status. The two hybrid groups also clustered discretely. Chloroplast typing confirmed the direction of crosses. The data further suggested that repeated reciprocal crossings occurred in the production of the hybrid cultivars.

OBJECTIVE The aim of this study was to evaluate predictors of malignancy in pancreatic lesions with suspicious or indeterminate endoscopic ultrasound fine-needle aspiration (EUS-FNA) cytology. METHODS Suspicious/indeterminate EUS-FNA cytology was identified from our database. Stable imaging, benign pathology, or survival for 12 months after EUS-FNA was considered benign. Diagnosis of malignancy was based on positive pathology, local invasion/metastasis on imaging, or death within 12 months from cancer-associated causes. Univariate analysis was performed to compare variables between benign and malignant lesions. Multivariate analysis (covariates: age [

We propose that the phrase repetitions in the canon per tonos from J. S. Bach's Musical Offering are not recognized by listeners as being successively upward. We examine possible causes for this effect and suggest that it may be due to Bach's use of chromatic harmony. To test this hypothesis, we conducted an experiment in which one group of listeners was presented with Bach's canon, while another group was presented with a modified version of the canon in which the harmonies were altered in order to make the upward phrase repetitions more apparent. We found that subjects recognized the ascending pattern in the modified canon with greater ease than they recognized the ascending pattern in Bach's canon. We also consider briefly why Bach may have wished to cause such an effect.

This article argues that the use of cooperative learning strategies in social studies instruction represents a natural match of method and substance. That is, cooperative learning provides the perfect vehicle for helping children understand and experience many of the essential concepts and values embedded in the social studies curriculum. This article focuses primarily on how classroom teachers can instruct their students in essential reading and writing skills while using social studies as the medium for discussion. A brief, illustrative review of the empirical literature on the use of cooperative learning approaches in social studies is followed by a general overview of representative cooperative learning methods and a more in‐depth description of a few specific reading and writing applications. Other potential applications of cooperative learning procedures are described as well.

Spiral enteroscopy can be safe and effective in the short term for evaluation of obscure GI bleeding, but long-term data are lacking.To assess the long-term clinical outcomes after deep small-bowel spiral enteroscopy performed for obscure GI bleeding.Prospective cohort study.Academic referral center.This study included 78 patients who underwent antegrade spiral enteroscopy for evaluation of obscure GI bleeding.Diagnostic spiral enteroscopy with hemostatic therapeutic maneuvers applied as indicated.Postprocedure evidence of recurrent overt GI bleeding, blood transfusion requirements, need for iron supplementation, serum hemoglobin values, and the need for additional therapeutic procedures.Long-term follow-up data (mean [± standard deviation] 25.3 ± 7.5 months; range 12.9-38.8 months) were obtained in 61 patients (78%). Among those with long-term follow-up data, overt bleeding before spiral enteroscopy was present in 62%, compared with 26% in the follow-up period (P.0001). The mean (± SD) hemoglobin value increased from 10.6 ± 1.8 to 12.6 ± 1.9 g/dL (P.0001). Blood transfusion requirements decreased by a mean of 4.19 units per patient (P = .0002), and the need for iron supplementation (P = .0487) and additional procedures (P.0001) decreased in the follow-up period. There were 8 adverse events (9%) (7 mild, 1 moderate).Single-center study, intervention bias.In patients with obscure GI bleeding, deep small-bowel spiral enteroscopy is safe and effective in reducing the incidence of overt bleeding. An increase in hemoglobin values along with a decrease in blood transfusion requirement, need for iron supplementation, and need for additional therapeutic procedures were found over long-term follow-up. (NCT00861263.).

Perforations are an uncommon but serious complication of endoscopy. Although they are well recognized, no universally accepted strategy for their management exists. The need for management algorithms in situations that call for multiple interventions in a short time, with coordinated effort encompassing multiple providers from different specialties, has long been recognized, but no such clinical care pathway has been developed for the management of endoscopic perforations. Since perforations are uncommon, a predetermined plan of action can streamline patient management. Furthermore, such a plan demonstrates preparedness on the part of the gastroenterologist. We developed an endoscopic perforation management strategy based on the best available scientific evidence and our specific resources. We report our experience in the hope that it may form a useful framework for gastroenterologists attempting to do the same at their own institution.

Polypectomy with cold biopsy forceps is a frequently used technique for removal of small, sessile, colorectal polyps. Jumbo forceps may lead to more effective polypectomy because of the larger size of the forceps cup.To evaluate the efficiency of cold jumbo biopsy forceps compared with standard forceps for polypectomy of small, sessile, colorectal polyps.Randomized, controlled trial.Outpatient endoscopy center.This study involved 140 patients found to have at least one eligible polyp defined as a sessile polyp measuring ≤6 mm.Polypectomy with cold biopsy forceps.Complete visual polyp eradication with one forceps bite.In 140 patients, a total of 305 eligible polyps were detected (151 removed with jumbo forceps and 154 with standard forceps). Complete visual eradication of the polyp with one forceps bite was achieved in 78.8% of the jumbo forceps group and 50.7% of the standard forceps group (P.0001). Biopsies from the polypectomy sites of adenomatous polyps thought to be visually completely eradicated with one bite showed a trend toward a higher complete histologic eradication rate with the jumbo forceps (82.4%) compared with the standard forceps (77.4%), but the difference did not reach statistical significance (P = .62). The withdrawal time for visual inspection of the colon and time to perform polypectomies were significantly shorter in the jumbo forceps group (mean 21.43 vs 18.23 minutes; P = .02).Lack of blinding to the type of forceps used.The jumbo biopsy forceps is superior to the standard forceps in removing small, sessile polyps. (NCT00855790.).

We report the successful classification, by artificial neural networks (ANNs), of1H NMR spectroscopic data recorded on whole-cell culture samples of four different lung carcinoma cell lines, which display different drug resistance patterns. The robustness of the approach was demonstrated by its ability to classify the cell line correctly in 100% of cases, despite the demonstrated presence of operator-induced sources of variation, and irrespective of which spectra are used for training and for validation. The study demonstrates the potential of ANN for lung carcinoma classification in realistic situations.

Sedation of patients for deep small bowel enteroscopy presents unique challenges and is traditionally provided by anesthesiologists. No study has directly evaluated gastroenterologist-guided, nurse-administered sedation for deep enteroscopy. Further, no comparison exists between gastroenterologist-guided versus anesthesiologist-guided sedation during deep enteroscopy. To evaluate safety and efficacy of performing deep (spiral) enteroscopy using gastroenterologist-guided sedation and compare outcomes between patients receiving gastroenterologist-guided and anesthesiologist-guided sedation. This prospective case series contains 91 consecutive patients who underwent deep enteroscopy with spiral Endo-Ease Discovery SB overtube. Of the patients, 64 received gastroenterologist-guided and 27 received anesthesiologist-guided sedation. In the 64 patients receiving gastroenterologist-guided sedation, successful completion occurred in 59 of 64 enteroscopies (92.2%). Mean insertion depth was 231.0 ± 85.8 cm beyond the ligament of Treitz. Total procedure time was 39.9 ± 15.7 min (diagnostic time 34.7 ± 12.3 min; therapy time 5.2 ± 8.9 min). Positive findings were noted in 32 cases (50.0%), with therapy performed in 27 cases (42.2%). Six minor complications occurred. Compared to the anesthesiologist-guided sedation group, there was no difference in patient characteristics except mean American Society of Anesthesiologists score (2.5 ± 0.5 in gastroenterologist-guided group versus 2.7 ± 0.6 in anesthesiologist-guided group; p = 0.046) and presence of adhesions (ten in gastroenterologist-guided group and zero in anesthesiologist-guided group; p = 0.030). Outcomes for both groups were not significantly different except for shorter times in the gastroenterologist-guided group (39.9 ± 15.7 min versus 46.0 ± 12.1 min; p = 0.047) and more frequent findings in the anesthesiologist-guided group (50.0% vs. 74.1%; p = 0.034). Deep enteroscopy using the spiral overtube can be successfully and safely accomplished with gastroenterologist-guided, nurse-administered standard sedation.

Background Gastrointestinal manifestations are frequently encountered in cystic fibrosis patients. Gastroparesis evidenced by a variety of diagnostic methods has been described in patients with cystic fibrosis, predominantly in children and in individuals with advanced lung disease. The presence of gastroparesis in adult patients with different degrees of lung involvement and its response to the acute and chronic administration of macrolides have not been reported. Methods Using the University of Florida Cystic Fibrosis database we identified symptomatic patients who had gastroparesis confirmed by a prolonged half-time during gastric emptying scintigraphy. Results Of 86 cystic fibrosis patients, periodically followed in our institution, we found five who had classical symptoms and prolonged gastric emptying half-time. Age 25.2±8 years, 80% females, BMI 22±9 kg/m 2 , HbA1c 5.8±0.6 g/dl, FEV1 53.2±15% of predicted. Gastric emptying half-time was 191.4±91.4 min (range 100–300 min) and decreased to 12.2±6 min (range 5–20 min) after IV administration of erythromycin ( p =0.043). Patients were followed up for 3±2.1 years. All patients but one, who was taking opiods, had good clinical response to PO macrolides. Conclusions Gastroparesis occurs in patients with cystic fibrosis, even in patients with relatively preserved lung function and in those without cystic-fibrosis related diabetes. Macrolides may be an effective therapy in cystic fibrosis patients with gastroparesis when administered acutely or chronically.

Our goal was to evaluate the 90/90 pillow as an effective means of preventing blood loss after knee arthroplasty. We performed a prospective randomized case-control study on 40 patients undergoing knee arthroplasty. All patients were treated in a standard fashion, except for the use of the 90/90 pillow in one group. The 90/90 pillow flexes the knee to 90 degrees and is in situ for 24 hours after surgery. We measured blood loss at time points from 1 to 48 hours. Range of motion was assessed, as were analgesic requirements. Statistical analysis was performed on our results. We found a statistically significant reduction in blood loss without compromising range of motion. We advocate the 90/90 pillow after all knee arthroplasties.

Ulanowicz in [1] defines ascendancy in terms of departure from maximum-entropy (proportional) flow; however he does not explain what may cause this departure. Here the ascendancy is derived by minimizing a cost function F= ∑ i,j=1ntij log tij+α ∑ i,j=1ntijcijwhere tij is the fraction of the total flow from input i to output j, cij is the corresponding cost of such flow, and α is a parameter (inversely proportional to temperature); the flow being subject to marginal flow constraints ∑ j=1ntij=ai for i=1 to nand ∑ i=1ntij=bi, for j=1 to n.Minimization of such a system is obtained by Evans in [2]. At high temperatures (small α>0) the first (min of negative entropy=max entropy) term dominates, but as α increases (temperature decreases), the cost function dominates, causing a departure from maximum entropy, or ascendancy. Riverbed analogy: At high temperature (fast flows) the flow is mostly uniform (max entropy) across the river bed, but at low temperatures (limited flow), the structure of the riverbed (cost f...

Objectives Feasibility of using split-dose bowel preparation in an inpatient setting has not been extensively studied. We conducted a single-centre multiphase study to (1) understand the perceived barriers to split-dose administration among nursing and providers, (2) develop and implement a split-dose electronic order set and (3) evaluate the use and impact of split-dose administration on 100 consecutive colonoscopies. Methods Nurse/provider interviews were conducted to understand perceived concerns and potential barriers to split-dose preparation. Next, an order set containing specific nursing instructions was developed, disseminated and implemented into the electronic health record as the default order set for inpatient colonoscopies. Finally, 100 consecutive inpatients undergoing colonoscopy were interviewed to determine prep consumption, tolerability and rate of procedural delays due to inadequate preparation. Results Survey results indicated perceived concerns about inpatients’ ability to tolerate and complete the preparation, insufficient nursing support and complexity of preparation administration. Based on this, prep orders were adjusted to accommodate nursing concerns prior to implementation. 54% of inpatients actually completed the bowel preparation in split doses (SPLIT group); the remainder had the conventional full dose preparation (NON-SPLIT). Less procedural delay and a lower rate of additional laxatives use (13% vs 30.4%) were seen in the SPLIT versus NON-SPLIT group. Split-dose preparation was well tolerated among inpatients. Conclusions Split-dose bowel preparation can be implemented for inpatients undergoing colonoscopy. This multiphase study demonstrates the steps used to implement split-dose preparation at our institution and may provide others with strategies that they could use at their institutions.

Management of Duodenal Perforations After Upper Endoscopic Procedures: Is a Non-Surgical Approach Tenable? Alejandro L. Suarez*, Dennis Collins, Anand Gupte, Shailendra S. Chauhan, Peter V. Draganov, Christopher E. Forsmark, Mihir S. Wagh Division of Gastroenterology, University of Florida, Gainesville, FL Background: Duodenal perforation is a rare but serious endoscopic complication. Management of duodenal perforations is not standardized and surgical intervention has been the traditional approach. Aim: To review the incidence, management and outcomes of duodenal perforations after upper endoscopic procedures. Methods: A retrospective review of our electronic endoscopic complications database and medical records was performed to identify patients with duodenal perforations after upper endoscopic procedures (EGD/ enteroscopy, EUS, ERCP) from 1/2000 8/2011. The study was approved by the IRB at the University of Florida. Medical records were reviewed to collect data on incidence, management and outcomes after duodenal perforation. Data collected included procedure indication, type of endoscopic procedure, time of diagnosis, radiologic test results, management via surgery or conservative measures, length of hospital stay and mortality. Results: 43,572 upper endoscopic procedures were performed during this period [30,038 EGDs (69%), 7,761 ERCPs (18%), 5,773 EUS (13%) ] leading to 18 duodenal perforations (0.04%). 6/18 (33%) perforations resulted from diagnostic procedures while 12/18 (67%) were from therapeutic endoscopies including duodenal EMR/polypectomy, dilation, EUS-FNA, sphincterotomy and stent placement. 8/18 (44%) were identified during endoscopy, 5/18 (28%) within 24 hours and 5/18 (28%) after 24 hours after endoscopy. 16/18 (88%) had radiographic imaging (15 CT scans and 1 abdominal X-ray) while 2 went straight to surgery. Overall, 12/18 (67%) underwent surgery with a mean length of stay of 28 days while 6/18 (33%) were treated conservatively with a mean length of stay of 10 days. Intraperitoneal free air was seen in 73% and retroperitoneal air was seen in 27%. Abdominal CT scan with oral contrast was used to detect duodenal extravasation and leak. Contrast extravasation was seen in 4/15 (27%) with all 4 patients (100%) undergoing surgery (2/4, 50% survived with a mean length of stay 13.5 days). Extravasation of contrast was not seen on CT in 11/15 (73%). Only 5/11 (45%) had surgery (all 5 survived with a mean length of stay 14 days) while 6/11 (55%) were treated conservatively (NPO, NG tube, IV fluids, antibiotics, percutaneous drain if needed), of which all 6 (100%) survived with a mean length of stay 10.3 days. Complications were seen in 4/18 (22%) patients (1 with fever that resolved with antibiotics, 1 sepsis, 1 post-ERCP pancreatitis and 1 abdominal abscess drained percutaneously). Overall, 2/18 (11%) patients died after duodenal perforation (both patients had contrast extravasation requiring surgery). Conclusion: Though limited by small numbers, our data suggests that patients with duodenal perforation without duodenal contrast extravasation on CT scan may be effectively managed conservatively without surgery.

Radioimmunoassay of angiotensin I was applied to the estimation of renin concentration after incubation of human plasma with an excess of renin substrate from plasma of anephric sheep. With this method markedly subnormal plasma renin levels were accurately measured. The technique was used in the study of 18 patients with proven aldosterone-producing adenoma (APA), 5 with hyperaldosteronism associated with bilateral adrenal hyperplasia, and 23 with essential hypertension. Plasma renin concentration (PRC) was extremely low in APA, and a significantly higher mean basal level of PRC was seen in hyperplastic aldosteronism ( P It is suggested that the prediction of a distinct APA can best be made in patients with hyperaldosteronism when the exact extent of renin suppression is taken into account and when DOCA is used to assess suppressibility of aldosterone. While such evaluation may defer surgery in some patients with correctable hypertension, it may reduce the number with persistent hypertension after bilateral adrenalectomy.

Excerpt Studies were performed on 80 hypertensive subjects. Thirteen of these patients, who were receiving oral contraceptive therapy when referred for evaluation, were studied during and after wit...